1/4/05njm

Welcome to the Domestic Violence in Native Women discussion. (see
background below)\*

Please each of you address these questions to be considered:

1.  Do you think that health care facilities should screen for domestic
    violence?

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1.  If yes, who should screen?

2.  How should screening be implemented at the facility level?

3.  How do you get involved community resources into your referral
    patterns?

4.  Have you identified domestic violence advocates in your local
    community?

**Yohanah Leiva**

**Mon 11/1/2004 3:30 PM**

Dear All,

1\. Yes

2\. Physicians, Nurse Midwives, Nurse Practitioners, Physicians
Assistants, Dentists, Nurses, Dental Techs, Psychologists

Social Workers\...

3\. Baseline measurements of who screens, who is screened; Education: DV
101, why it is pertinent to healthcare, how to screen empathetically,
etc.; what are the local resources, how accessed, what are the reporting
laws, how are the laws enforced, are the written materials,
documentation for screening, policies and procedures, referral
mechanisms for positives, safety/lethality assessment, in place?

Need a task force and at least one passionate person to drive the
effort. Need a team.

Need to insure proper coding a data measurement plans.

4\. In our task force we work with our local advocacy NGO ADABI, the
police and a widening community agency pool of representatives. We
telephone those resources needed for the individual patients and write
referrals.

5\. Yes, our local DV/IPV advocacy group ADABI are long standing and a
very well respected, well run group.

**Burton Attico**

**Mon 11/1/2004 5:50 PM**

Concur with all that has been said thus far. However, screening must be
done in a non-threatening, supportive, nurturing manner, or the
screening itself can become abusive. We should also remember that, while
domestic violence is most commonly thought of as male on female, it
could also be the opposite. The screening must be done in such a manner
that the person is not \"exposed\" in such a manner that they feel that
they are again being threatened and abused, by \"the system.\"

**Scott Hamstra**

**Mon 11/1/2004 6:24 PM**

Dear All

1\. Do we really need to ask this? \-- Yes yes YES!

2\. \~Everyone

\-- Some patients may reveal more to a nurse than a doc - some may
reveal more to one gender or the other

3\. This is an interesting question and likely will invoke lots of
discussion and comments \...

\- Is it worth screening everyone at every clinic visit \-- or focus on
certain perceived high-risk groups?

\-\-\-- certainly makes some sense to try to pick the low hanging fruit
first.

There are studies that show a high % of ER patients have DV issues from
experience \-- patients with multiple somatic complaints, substance
abuse & depression are related to DV from experience \-- pregnancy is
high risk

The AAP recommends asking at well baby visits \-- babies can be/are \"a
high stress\" \-- and also are at risk

wonder if not keeping appointments is a red flag

\'Certainly agree that staff would address this better if they know more
about DV and learn how to ask questions....even after \... staff know
about it \.... and learn to ask / screen \...

\-\-- they also need to know how to document on the PCC \-- so data
entry picks up the data and gets it into RPMS

Staff also need to know \-\-- what the local resources are \... and how
to access them \-- during the day Vs 2 AM on a Sat night.

4\. Multi-disciplinary experience and a growing database \-- will raise
both individual and facility awareness of the problem which has been
mostly hidden or overlooked throughout the USA \-- at some point \-- a
local champion may surface \-- or the problem may \"grow\" in rank
compared to other local problems so that it can no longer be ignored and
can get both more administrative and more financial support. In the end
\-- it is a \"social\" or \"community\" problem \-- that will only
decrease with cultural change. Helping the community acknowledge and
begin to address this can be very challenging. Social services, schools,
police, tribal courts \-- all can contribute to this cultural shift.

5\. We have advocates locally \-- social services, behavioral health,
tribal prosecutors, police \-- have all joined at some level.

It really began as Child Protection \-\-- fairly easy to get folks to
accept the need to protect children \-\-\-\-- and then it\'s easier
though not easy to make the step or leap to protecting big kids (i.e.
adults) as well. It\'s never enough, never fast enough \-- but a journey
of a 1,000 miles starts with a single step - and just keep taking those
steps.

**Donald Clark**

**Tue 11/2/2004 12:54 PM**

I\'m sorry to be so long-winded. I hope people can learn something from
our experience in Albuquerque, so as not to reinvent the wheel.

1\. Do you think that health care facilities should screen for domestic
violence?

All healthcare facilities should screen for DV. Yes, we do need to ask
this, and make it clear that the answer is yes. There remain plenty of
doubters. From the public health perspective, DV fulfills most if not
all the criteria suitable for screening large numbers of people. This is
true from the standpoint of the \"disease\" in terms of prevalence in
our patient population, severity, known natural history, etc. And in
terms of screening tools that are sensitive, specific, etc. and
acceptable to patients and to administrators in terms of the cost of
screening. My qualification \"most\" is only due to the fact that
relatively few outcomes based studies show that interventions exist and
are effective. This has more to do with the fact that relatively few
such studies have yet to be completed. Those studies that looked at
outcomes show that interventions are effective in increasing safety
behaviors, and demonstrate less morbidity and mortality in the
\"treated\" groups.

The USPSTF recently reported that there was not enough information to
recommend routine screening. The process behind this recommendation was
presented at the October DV conference sponsored by the Family Violence
Prevention Fund, and compared by an epidemiologist to the processes used
to give stronger recommendations for things like nursing, and fluoride
supplementation. The very quick summary is that this recommendation from
the USPSTF was based on (memory serves): no demonstrable connection
between screening and improved outcomes, no studies demonstrating that
screening or treatment caused no harm, and a lack of standardized
screening tools. For me the bottom line was that DV screening actually
held up quite well in these head-to-head comparisons, and the weak
recommendation is a mystery.

2\. If yes, who should screen?

Everyone should feel comfortable screening and knowledgeable as to what
should happen next in your facility when you get a positive response.
But we know that when it\'s everyone\'s job, then no one does it. We\'ve
learned the hard way in Albuquerque that screeners must be held
accountable. We\'ve had to make it part of the job evaluation.

Regarding whom should screen. My experience is not WHO but HOW. I\'ve
been impressed how eager women are to discuss this issue, as long as the
provider is sincere, respectful and culturally appropriate, with proper
regard to confidentiality and safety. I am sure that some women have not
disclosed to me, a big white male in a position of authority. But many
have been very willing to discuss this issue with me. And grateful. We
are often the first person(s) to hear about this. There are lots and
lots of studies showing that patients are fine with such questions.
Studies in a number of clinical settings: ER\'s, OB/GYN, FP, Internal
Medicine. In VA\'s and on reservations. We providers are the ones who
need to get comfortable with this. Many of our patients are -literally-
dying to tell someone.

3\. How should screening be implemented at the facility level?

I think a passionate champion is good, but it\'s helpful to have a team
approach, if your facility is large enough. This is an emotionally
difficult issue to deal with, and it\'s helpful to have peer support.
From a practical standpoint, it\'s helpful to have as much input from as
many departments as possible to nail down the details of who will
screen, where and how the screen will be performed (e.g. written or
verbal), how it will be recorded in the record and entered into RPMS.
Nurses have been very helpful at all levels, including the practical
issue of location and timing of screening at this facility. The
documentation of screening moms at well child visits is an especially
controversial one, and medical records can help there, too.

And that\'s all after you\'ve decided whom to screen and how often. If
you are screening at all, then good for you. Let\'s remember, though,
that if we are screening targeted groups at special times, then we will
miss some/many. At a minimum - and this is just me talking - I think we
should be screening all women who present to ER or UC with or without
injuries, or presenting to clinic with injuries, inpatients, women at
health maintenance visits, and at least twice during prenatal care and
postpartum checkup. My experience has convinced me that there should be
no age limits on screening. I acknowledge that men can be victims of DV,
but I don\'t screen men for DV because I\'ve not seen any data to
convince me that it is very prevalent in that population.

We should remember to be up front before screening as to the limits of
confidentiality. Examples: State or tribal reporting requirements of DV?
How the response will be documented in the medical record (and why it\'s
in the patient\'s best interests to do so), As well as the need to
report any concerns about concurrent child abuse.

There are many other categories of patients to screen if you\'ve decided
to screen only targeted groups. \"Noncompliance\" and \"uncontrolled
\_\_\_\_\_\_\_\_\" (you fill in the blank with anything you want) are
groups I\'ve learned to pay more attention to. Yes, failure to keep
appointments would fit in here. Patients with any chronic pain syndrome
(headache, pelvis, and stomach) are more likely to be or have been
victims of current or past physical or sexual abuse. And the more the
symptoms, the worse the abuse.

The more work that\'s put in up front, the easier it will be to
implement your screening plan. Time spent getting everyone on the same
page regarding screening and dealing with positive responses, is time
saved.

Lastly - expect, respect, and have a plan to deal with the level of DV
experienced by your own facility\'s staff. This can be a major obstacle
to screening implementation. So many have experienced DV personally in
present or past, or watched a loved one experience it. Some research
(presented at the same conference mentioned above) indicates that the
more closely we identify with the victim, the less empathy we feel. This
may seem counterintuitive, but it does fit with our experience in
Albuquerque. The current or past victim of DV, or the mother or daughter
or sister of one, often is NOT the best person to have doing the
screening.

4\. How do you involve community resources in your referral patterns?

We are very fortunate to have a local advocacy group for Native Women.
The advocates are uniformly well trained, experienced and readily
available to come to clinic if necessary. Invite them to your facility,
perhaps to a DV team meeting, or for a presentation. They are very eager
to help. And they can offload a lot of the work for you.

Regarding any referral, get the patient\'s consent first. An automatic
notification to Social Services, Behavioral Health or the local advocate
is a betrayal of trust. This is also another hit on her autonomy. If the
referral is not legally required, regardless of how obviously helpful
you think it will be, and the patient declines it, then don\'t make the
referral.

I feel I\'ve taken up too much space. If others have questions, please
feel free to contact me through this page or directly.

**Eklund, Stephanie \[seklund@ANMC.ORG\]**

**Wed 11/17/2004 9:36 AM**

I\'m sorry to join the discussion so late.  Here in Alaska we have many
of the same challenges the rest of you face, as many of our patients are
from remote villages that may not have the same resources we have in the
cities.  However, there are many innovative ideas that are being worked
on throughout the state.  One of these are safe houses in the smaller
villages that allow people to stay in the communities while not feeling
trapped in an unsafe place.  Obviously this is a short term situation,
but it allows people to have somewhere to go in a crisis.

One of the other programs in our institution is called the Family
Wellness Warriors Initiative.  The main goal of the initiative is to
keep families together if possible by re-defining the roles of the
individuals in a culturally sensitive way.  For example, men are
encouraged and trained to be protectors of the family, and anger is
discussed as a legitimate response to a threat on the family, not within
the family.  Women are protectors and keepers of the traditional values,
which of course are reflected in the children.  There\'s a lot more to
it, but the members of the initiative are traveling and speaking
throughout the state in order to prevent violence.  They also coordinate
with resources available in the community, especially the shelters, as
needed. 

Of course, there is the question of response once violence has occurred
in the family.  Currently we are working on a culturally-sensitive
training program that will help providers know how and when to discuss
family violence with our patients.  Unfortunately, when we simply asked
people to \"ask the question\" it was often done in appropriate ways and
places.  Our emphasis is on a supportive relationship with people that
will provide an environment of trust and empathy.  Currently there are
behavioral therapists and social workers \"assigned\" to some of the
primary care clinics so that they are readily available to help if a
person discloses being harmed or threatened.

Thank you for letting me participate in this discussion.  It\'s exciting
to hear from other people with a passion in this area.

**Long, Bernard (FT) \[blong@ABRMAIL.IHS.GOV\]**

**Wed 11/17/2004 10:38 AM**

Regarding "Safe House" concepts:

What are the requirements, competence level, of staff at the safe house?

At Ft Thompson Service Unit, we have questions, concerns over legalities
and liability for paid and unpaid volunteers, Federal Employees
assigned, and Commissioned Officers volunteering for or being directed
to staff the Safe House.

If there is a "safe House" established and say a pharmacist working
after hours, volunteering in the evening, and a situation arise whereby
someone gets hurt by accident or an intentional act. Who bears the risk?

We all want to do good things and are willing to extend to community,
but the GOOD SAM law only goes so far and may not be available for
professionals.

As a supervisor, does one assure that his sub inordinate is "covered" in
some way?

Just some thoughts regarding risk management.

Bernie Long

**Eklund, Stephanie \[seklund@ANMC.ORG\]**

**Wed 11/17/2004 11:45 AM**

The safe houses in the community are really a grassroots effort by
people in the village itself to provide a temporary safe place for
people in crisis. The shelters in the cities like Anchorage are staffed
by advocates with all the regulations required for a public facility. 
I\'m not aware of any shelters around that are staffed by IHS or federal
employees per se.

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Wed 11/17/2004 3:27 PM**

Thanks for the recent email postings.

Are there any other issues that relate to domestic violence in your
facility and/ or community?

What can the health care facility do to help increase recognition of
this problem?  How do we increase cultural awareness in the screening
area? Do you worry about confidentiality when a patient screens
positive?

Here are some URL's that contain additional information about domestic
violence, and resources for our providers.

Remember, there remains a GPRA indicator for domestic violence screening
for FY 05.

 

DV ppt presentation

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DV102704.ppt>

The Primary Care Forum page under the DV Discussion to find both the
initial discussion and the ppt posted

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp>

 

Here is the IHS Violence Against Native Women page

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV00.cfm>

Thanks. Terry

**Long, Bernard (FT) \[blong@ABRMAIL.IHS.GOV\]**

**Thu 11/18/2004 10:01 AM**

Our safe house situation is for respite for suicidal kids and young
adults.

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Wed 11/24/2004 9:15 AM**

Make sure to look at the IHS Primary Care Provider, October 2004.

The lead article is: Domestic Violence Pilot Project, Hussong et al

This primary care discussion forum on violence against native women will
end soon; please share any other thoughts that you may have about this
issue with others on the list serve.

And,  have a great Thanksgiving!

Terry

**Hamstra, Scott (WIH) \[Scott.Hamstra@IHS.GOV\]**

**Wed 11/24/2004 10:31 AM**

Did you read that article I forwarded to you that compared the right
wing politics to "abuse"?

Interesting huh?

Should ask Denise to look at that and get an expert's feedback.

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Wed 11/24/2004 12:32 PM**

If people are interested in seeing this article, please email Scott
Hamstra. Thanks. Terry

<Scott.hamstra@ihs.gov>

**Murphy, Neil**

**Thu 11/25/2004 7:10 AM**

On a slightly different tack....

Here are two recent articles that describe violence and abuse, and how
it can be missed, at both ends of the age spectrum, e.g., elderly and
children

**Intimate Partner Violence: What Are Physicians\' Perceptions with
older patients?**

CONCLUSIONS: Continued provider training about IPV should include
information on identifying older victims and appropriate management
options. Participants stressed the importance of community efforts to
raise awareness and improve resources available for older women who are
victims of IPV.**         **

Zink T, Regan  et al Intimate partner violence: what are physicians\'
perceptions? J Am Board Fam Pract. 2004 Sep-Oct;17(5):332-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355946>

**Abuse in childhood and adolescence as predictor of future
victimization**

Violence Against Women: Identifying Risk Factors summarizes two studies
that used different methodologies and samples to determine the extent to
which physical and sexual abuse during childhood or adolescence
contribute to later victimization. The research brief, published by the
National Institute of Justice, describes the methodologies, limitations,
and findings of the two studies. The first study followed college-age
women and men for 4 years, asking them questions about past and current
victimization each year. In the second study, researchers asked urban,
low-income, mostly black women who had substantiated child sexual abuse
about their adolescent and adult victimization. The brief also presents
information on prevention strategies, and it includes references. It is
intended for use by service providers and counselors working with
adolescents and young adults, victims\' and women\'s advocacy groups,
and researchers. <http://www.ncjrs.org/pdffiles1/nij/197019.pdf>

**Leiva, Yohanah \[Yohanah.Leiva@IHS.GOV\]**

**Tue 12/14/2004 11:13 AM**

Do you have any information on validity and reliability testing of the
GPRA+ IPV?DV screening recording tool that is used by the RPMS coders;
the neg

present\<1yr

past \> 1yr 

unable to screen

refused screen

??

I will do a pilot study here now that we have the PCC+ written and in
use and the language straight with the RPMS coders.  However I would
love to know if it\'s been tested

**Clark, Donald \[dclark@ABQ.IHS.GOV\]**

**Thu 12/16/2004 7:12 AM**

We\'ve been testing it here. Nothing as fancy as validity and
reliability. But it sure makes it a lot easier to recover the info
regarding your screening. If I understand your question, the validity
and reliability would apply more to your screening instrument, not to
the way in which the results of screening are entered into RPMS. --DC

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Tue 12/21/2004 12:31 PM**

Maternal Homicide Washington Post: Information on homicide in pregnancy

\"But in their study, published in the Journal of the American Medical
Association in 2001, they wrote that in Maryland, \"a pregnant or
recently pregnant woman is more likely to be a victim of homicide than
to die of any other cause.\"

\"It was a huge surprise,\" said Horon, who recalls paperwork covering
the researchers\' kitchen tables on weekends and evenings as they sought
to understand the astonishing numbers. \"We thought we had to have made
a mistake. We kept checking and checking and rechecking.\"

Their findings, as it turned out, were no error. Homicide accounted for
50 of 247 maternal deaths in Maryland over a six-year period \-- more
than 20 percent. It had caused more deaths than cardiovascular
disorders, embolisms or accidents.

\"People have this misconception that pregnancy is a safe haven,\" Cheng
said.

**Editor's Note:**

Here is a posting for more information on the article mentioned above:

**Washington Post Three-Day Series Examines Homicide of Pregnant Women,
New Mothers**\
<http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=27336>

**Andrew, Bridget \[bandrew@ABQ.IHS.GOV\]**

**Tue 12/21/2004 3:41 PM**

Thank you very, very much for sending this email.

 

I, and other women were struck by how it seemed to take the media a day
or two to acknowledge that "the miracle baby" had a mother, and that the
mother's life, that of an adult woman, was brutally and randomly taken.
I am ashamed to see how incredibly misogynist our culture has become,
and I am reminded of why violence and abuse of women is so pervasive \--
in the media, and the home.

 

I look forward to pulling up the article you cited, and posting it for
staff members to read.

 

Thank you again for your commitment to keeping this issue visible, and
working to improve women's lives!

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Tue 12/21/2004 5:10 PM**

The \"media\" does not acknowledge that:

1\. Not being pregnant is far safer than being pregnant;

2\. Homicide is one of the leading causes of death in the reproductive
ages.

3\. Pregnancy exposes women to some risks that do not exist during the
non-pregnant state, and put her at increased mortality risk.

Arizona had a very active Maternal Mortality Committee at one time, but
it went out of existence largely because of hospital \"risk managers\"
and the inability to continue to secure medical data/info for review. We
are hoping to restart this body, and are seeking enabling legislation.
ACOG has been pushing this move also, nationwide (Perinatal/Fetal/Infant
Mortality Review).

We must also push to decrease the rate of unintended pregnancy,
presently almost half of all completed pregnancies. It is rare that a
woman comes in telling you that she is planning a pregnancy, and getting
ready for that pregnancy, but it is usually to find out if she is
pregnant.

**\*Background**

**What is Domestic Violence?**

Domestic Violence, or intimate partner violence (IPV) as it is widely
becoming known, is an urgent public health problem. IPV/DV is not
confined to any ethnic, religious, racial, socioeconomic, or age group.
It occurs among heterosexual women, men, and adolescents and also among
lesbian, gay and transgender, and bisexual (LGTB) individuals. The
devastating impact of IPV/DV on women, children, and families has been
well documented.

Intimate Partner Violence has been defined by the Family Violence
Prevention Fund (FVPF) as a \"pattern of purposeful coercive behaviors
that may include inflicted physical injury, psychological abuse, sexual
assault, progressive social isolation, stalking, deprivation,
intimidation, and threats. These behaviors are perpetrated by someone
who is, was, or wishes to be involved in an intimate or dating
relationship with an adult or adolescent victim and are aimed at
establishing control of one partner over another\". Domestic Violence is
a chronic condition that is treatable but if left untreated, the
severity and frequency of the abuse can worsen resulting in serious
physical injury and even death.

**Why Screen for Domestic Violence?**

Health care providers are in a unique position to help victims of IPV/DV
who seek routine or emergency care. Unfortunately, health care providers
too often miss this golden opportunity because they are not trained to
screen patients for abuse and because standards for documenting
screening results do not exist. Currently, there are no ICD-9 or CPT
codes specific to screening for IPV/DV. Properly trained doctors,
nurses, dentists, behavioral health, and other health care providers are
uniquely qualified to intervene to help victims. Simply by routinely
screening patients for IPV/DV and providing them with appropriate
information and referrals, health care providers can make an enormous
difference for victims and their children.

Screening for IPV/DV is quickly becoming standard of care. It is
recommended by the American Medical Association, American Academy of
Family Physicians, the American College of Physicians, the American
College of Obstetricians and Gynecologists, and many other professional
health care organizations. While the US Preventive Services Task Force
(USPTF) asserts that the effectiveness of screening has not been
validated, they also state that screening is justifiable on other
grounds. They site the high prevalence of undetected abuse among female
patients, the low cost and low risk of screening, the adverse economic
and social impact of abuse, and the nature of domestic violence as a
chronic, life-threatening condition as sound reasons for screening.

Also, domestic violence screening is a JCAHO mandate and a GPRA + (CIRS)
clinical performance indicator. The FY 2005 indicator states that the
IHS will ensure that 15% of women between the ages of 15 and 40 are
screened for domestic violence. GPRA + (CIRS) will query RPMS for the
IPV/DV screening exam code.

Major url is

[www.endabuse.org-](../../../../../../../../exchweb/bin/redir.asp%3FURL=http://www.endabuse.org-)
family violence prevention fund