# Presentation: 087699

## Take Home Tips from the Ketchikan Indian Clinic Domestic Violence Project

- Improve the System – Improve the Outcome
- Native Women’s Health
-  and
- MCH Conference
- August 15, 2007

## Presenters

- Ketchikan Indian Center, Ketchikan  AK
-  Lynn Hoefer, DV Advocate
- PIMC Center of Excellence
- Denise Grenier, MSW, LCSW
- Project Officer, IHS-ACF DV Pilot Project

## Presentation Objectives

-  Define three principles of a successful IPV/DV screening initiative
- Understand the RPMS tools available for increasing IPV/DV screening rates
- Identify up to three motivational methods that can be used to encourage providers to screen for IPV/DV

## Definition of IPV/DV

- Intimate Partner Violence is a **pattern of assaultive and coercive behaviors** that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivations, intimidations 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, and are **aimed at establishing control** by one partner over the other.
- Source:  Family Violence Prevention Fund

## Prevalence

- Nearly one-third of American women (31%) report being physically or sexually abused by a husband or boyfriend at some point in their lives, according to a 1998 Commonwealth Fund survey.
- In the US a woman is more likely to be raped, injured, assaulted or murdered by a male partner than any other type of assailant.

## Prevalence Among AI/AN

- A recent report from the U.S. Bureau of Justice Statistics found that Native Women are **five **times more likely to be a **domestic violence homicide victim** than the rest of the population.
- Native women are more than twice as likely to be victims of violent crimes committed by an intimate partner and are three times as likely to be victims of sexual assault than any other single grouping in the U.S.

## Facts

- Domestic Violence is the
- ...leading cause of injury among women of reproductive age
-  ...the single most common trigger for female suicide
- ...up to 60% of women who are murdered  die as a result of a domestic dispute
- Webster 1995
- Murder is the leading cause of death related to pregnancy
- JAMA 2001

**Notes:**
In a study done in Maryland  25% of deaths in women that occurred during or in the year following pregnancy were murder.
Put 2 and 2 together ......

These are the ones we know about

## Health & Domestic Violence

- In addition to the immediate trauma caused by abuse, domestic violence is associated with a number of chronic health problems including chronic pain, depression and alcohol and substance abuse.
- American Medical Association
- APA
- American College of Obstetricians and Gynecologists
- American Public Health  Association

## Health & DV continued 

- The management of other chronic illnesses such as obesity, asthma, seizure, diabetes and hypertension may be more complicated because of DV.
- DV can also diminish responsible sexual behaviors and complicate a woman’s ability to use appropriate contraception, cause unintended pregnancies, sexually transmitted infections (STIs) and HIV.

## Healthy People 2010

**	****Domestic violence is associated with 8 of the 10 Leading Health Indicators for Healthy People 2010**
**(Office of Disease Prevention & Health Promotion, DHHS****)**

##  Healthy People 2010

- _Indicator_			_Connection with DV_
- Tobacco Use		 ↑ risk of smoking
- Substance Abuse	 ↑ risk of high risk alcohol
- Injury & Violence  	 Leading cause of injuries 				    and homicide
- Mental Health		 ↑ risk of mental health 				    problems

**Notes:**

Healthy People 2010 reference:

US. Department of Health and Social Services.  Healthy People 2010 (Conference Edition, in two volumes). Washington, DC; 2000

## Healthy People 2010

- _Indicator_		_Connection with Domestic Violence_
- Responsible 		↑ sexual-risk taking and STI’s
- Sexual Behavior 	 Less likely to use condoms consistently
- Access to 		↑ risk of late entry into prenatal care
- Health Care
- Immunizations	Children of battered women less 					likely to get immunizations
- Overweight & 	Poor nutritional behaviors
- Obesity

## Why Health Care?

- The health care system is positioned to play a pivotal role in domestic violence prevention and intervention.
- Virtually every woman interacts with the health care system at some point in her life – routine health maintenance, prenatal care, childbirth, illness and injury or well child care
- Routine screening and assessment, with its focus on early identification and its capacity to reach patients whether or not symptoms are immediately apparent, is a primary starting point for reaching people who have never talked to anyone about domestic violence in their home.
- When victims of domestic violence are identified in the medical setting, providers can assist them in breaking through their isolation, understanding their options, living more safely within the relationship or safely leaving the relationship.

## Agency Responses to IPV/DV

**Clinical Quality Initiatives**
- IHS-ACF DV Pilot Project

## Justification for Screening

- US Preventive Services Task Force (USPSTF)
- Effectiveness of screening has not been validated but...
- Screening is justifiable on other grounds including:
- High prevalence of undetected abuse among female patients
- Low cost and low risk of screening
- Adverse economic and social impact of abuse
- DV is a chronic, life-threatening condition that is treatable – if abuse is left untreated the severity and frequency of abuse often worsens

## Justification for Screening

- Recommended by:
- American Academy of Family Physicians
- American College of Physicians
- American Medical Association
- American College of Obstetricians and Gynecologists
- JCAHO Mandate
- GPRA Clinical Performance Measure
- Women want to be asked!

## Guiding Principles

- Safety of victims and children
- Respect for the integrity and authority of the victim’s choices
- Perpetrators are responsible for starting and stopping violence

## CRS 2007 GPRA Measure and Target

- Female Active Clinical patients ages 15-40 who are screened for intimate partner (domestic) violence at any time during the Report Period, including documented refusals in past year
- 2007 Target:  Maintain the FY 2006 rate of 28%

## GPRA Performance 2004-2007

- National GPRA performance has increased significantly since this measure was introduced in 2004!
- Final GPRA 2007 aggregate results not yet available.

## Domestic ViolenceGPRA Clinical Performance Measure

- During FY 2008
- The IHS will maintain the domestic/intimate partner violence screening rate in female patients ages 15-40 at the FY 2006 rate of 28%.
- IHS 2010 goal for DV/IPV Screening
-  40% for female patients ages 15-40

## Clinical Objectives of CRS IPV/DV Screening Measure

- Objective
*To encourage routine screening *
- Standard
- Adult females should be screened for domestic violence at a *new encounter *and *at least annually*;
- Prenatal patients should be screened *once each trimester*
- 	*Source:  Family Violence Prevention Fund

## What Counts as Screening?

- Any of the following during the Report Period
- Patients with documented IPV/DV exam
- Patients with IPV/DV-related diagnosis
- Patients provided with patient education or counseling about IPV/DV
- Patients with documented refusal in past year of an IPV/DV exam or IPV/DV-related education

## What Counts as Screening (cont’d)?

- Patients with documented IPV/DV exam during the Report Period
- PCC Exam 34 (Intimate Partner Violence)
- BHS IPV/DV Exam
- IPV/DV exam is the preferred method for screening
- Demonstrates intentional screening
- Captures screening result

## What Counts as Screening (cont’d)?

- Patients with IPV/DV-related diagnosis during the Report Period
- POV or current PCC or BHS Problem List:  995.80-83, 995.85 (adult maltreatment), V15.41, V15.42, V15.49 (history of abuse)
- BHS POV 43.* (Partner Abuse), 44.* (Adult Abuse)

## What Counts as Screening (cont’d)?

- Patients with patient education or counseling about IPV/DV during the Report Period
- Patient education codes containing “DV-" or  "-DV“
- POV V61.11 Counseling for victim of spousal and partner abuse

## What Counts as Screening (cont’d)?

- Patients with documented refusal in past year of an IPV/DV exam or IPV/DV-related education
- Any PCC refusal in past year with Exam Code 34
- BHS refusal in past year of IPV/DV exam
- Any refusal in past year of Patient Education codes containing "DV-" or "-DV"

## Documenting IPV/DV Screening in RPMS

- Screening results are recorded as an “exam”
- Providers and Data Entry need to communicate about documentation of screening results
- Providers need to know how and where to record results on the PCC Encounter Form
- DE needs to know where to look for documentation and how to record in RPMS
- Date of screen, provider’s initials and result will appear on the Health Summary

## Documenting IPV/DV Exam in RPMS (cont’d)

- PCC
- POV
- Stamp
- PCC+
- BH applications (BHS v3.0 and BH GUI)
- Direct provider entry of screening results when recording a visit
- Wellness tab in BH GUI
- IHS Electronic Health Record
- Direct provider entry
- Exam component (typically on Wellness Tab)

## Documenting IPV/DV Screening in RPMS (cont’d)

- Allowable Results of IPV/DV Screen
- Negative:  Patient denies being a current or past victim of DV
- Present:  Patient admits to being current victim of DV
- Past:  Patient denies being a current victim, but admits being a past victim of DV

## Documenting IPV/DV Screening in RPMS (cont’d)

- Unsuccessful attempts to screen should also be recorded
- Refused (REF)
-  Patient declined exam/screen
- Unable to screen (UAS)
- Acceptable reasons for UAS
- Partner present
- Verbal child present

## Improving Screening Rates with RPMS

- PCC and BHS Output Reports
- Controlled by a security key
- Local data by clinic, provider and patient (vs. aggregate national CRS data)
- Timely data for peer reviews and performance improvement efforts
- Identify providers/clinics with high screening rates
- Identify providers/clinics with low screening rates
- Health Maintenance Reminder
- Displays on Health Summary
- Reminder to screen is provided at the point of care
- Immediate access to patient’s screening status

## PCC and BHS Screening Reports

- Tally and listing of all patients receiving IPV/DV screen including refusals, sort by:
- Date range
- Age
- Gender
- Result
- Provider (of exam, if available; Primary Provider of Visit, PCP)
- Date
- Clinic
- POV
*   ***Note: These reports are not meant to be used in place of CRS for GPRA reporting; they are for local use only.** *

## Health Maintenance Reminder

- IPV/DV Health Maintenance Reminder
- Title:  DV-IPV Screening
- Triggered by Exam Code #34
- Default Parameters (based on GPRA Measure)
- Females
- 15 years- 40 years
- Yearly screening
- *HMR Parameters can be changed to reflect a facility’s screening policy

## Health Maintenance Reminder

- Displays on Health Maintenance Reminder (HMR) component of Health Summary
- HMR has to be added to each type of HS
- HS Display
- Title of Screen *and the notation:*
- “May be Due Now” *or*
- Date Last Done
- Screening Result
- Initials of Provider who screened

## Agency Responses to IPV/DV

- Clinical Quality Initiatives
**IHS-ACF DV Pilot Project**

## IHS-ACF DV Pilot Project

- Multi-year project beginning in 2003
- 9 sites originally funded – now expanded to 20 sites
- End of the year Administration on Children and Families and IHS monies
- Efforts to secure recurring funds and
-       “institutionalize efforts”
- Partners: Mending the Sacred Hoop Technical Assistance Project, Sacred Circle
- Technical Assistance: Family Violence Prevention Fund

## Project Goals

- Raise the visibility of domestic violence as a public health issue
- Build stronger advocacy for domestic violence prevention and intervention in the health care setting
- Improve the health care facility response to domestic violence

## Project Goals Cont.

- Development of:
- Model policies and procedures
- RPMS screening tools
- Posters & safety cards
- AI/AN Best Practices Manual
- Exploring dental response
- Increase awareness of Sexual Assault

## Goals

- Training and TA to other I/T/U facilities
- Increase national awareness among I/T/U healthcare facilities that DV is a public health issue and disseminate the model for broad reform
- Presentations at regional and national conferences
- Articles
- IHS website and CCC on-line newsletter
- Tribal, IHS and HQE committee membership

## Team Activities 

- Facility-level
- Multi-disciplinary teams with monthly meetings
- Administrative leadership, medical and dental, behavioral health, DV advocate, security, and other interested staff
- Staff and community training and awareness activities
- Facility assessment:  Delphi Instrument (standardized tool to measure a health care facilities ability to respond to DV)
- Project-level
- Quarterly conference calls and project reports
- Delphi Instrument (every 6 months)
- Project trainings and meetings (2 per year)

## New Sites

- Standing Rock Service Unit
- McLaughlin PHS Health Center (McLaughlin, SD)
- Ft. Yates PHS Hospital (Ft. Yates, ND)
- Phoenix Indian Medical Center (Phoenix, AZ)
- Sells Service Unit
- Sells PHS Indian Hospital (Sells, AZ)
- San Xavier Health Center (Tucson, AZ)
- Tucson Indian Center

## Continuing Sites

- Cherokee Indian Hospital (Cherokee, NC)
- Chinle Comprehensive Healthcare Facility (Chinle, AZ)
- Crow/Northern Cheyenne Hospital (Crow Agency, MT)
- Kaw Nation—Kanza Health Clinic (Kaw City, OK)
- The N.A.T.I.V.E. Project Inc. (Spokane, WA)
- United American Indian Involvement, Inc. (Los Angeles, CA)
- Utah Navajo Health System (Montezuma Creek, UT)

## Senior Sites

- Feather River Tribal Health, Inc. (Oroville, CA)
- Rosebud IHS Hospital (Rosebud, SD)
- Zuni Comprehensive Community Health Service (Zuni, NM)
- Mississippi Band of Choctaw Indians - Choctaw Health Center (Choctaw, MS)
- Ketchikan Indian Corporation Tribal Health Clinic (Ketchikan, Alaska)
- Warm Springs Health & Wellness Center (Warm Springs, OR)
- Houlton Band of Maliseet Indians (Houtlon, ME)
- Crownpoint Healthcare Facility/Family Harmony Project (Crownpoint, NM)

## IHS-ACF DV Project Sites Aggregate GPRA Results

- 2006 Results
- Project site aggregate rate: 36%
- Agency aggregate rate: 28%

## Defining Success

- Our job is not to “fix” domestic violence or to tell victims what to do
- We can help victims by understanding their situation and recognizing how abuse can impact health and risk behaviors
- Success is measured by our efforts to reduce isolation and to improve options for safety

**Notes:**

Inappropriate expectations of what should happen when we screen and intervene for domestic violence can lead to frustrations among service providers and be harmful to victims  

 Qualitative research like the insightful work by Barbara Gerbert and associates (1999) describes the positive impact we can have by acknowledging abuse and confirming a client’s self-worth.  Providing support and information can make a difference in the lives of victims.  

McFarlane et al, (1998) found that pregnant women who were screened and offered a brief intervention protocol reported a significant increase in the number of safety behaviors before and after pregnancy 

## Defining Success

- Create a safe environment for screening and disclosure
- Give supportive messages to victims
- Educate patients about safety behaviors and strategies for self-care
- Inform patients about community resources
- Educate patients about the health effects of domestic violence

**Notes:**
There are many simple strategies to create a safer environment for screening and intervention with victims of domestic violence.  These strategies include:
Displaying posters, pamphlets, and information on services for victims and perpetrators
Having information on domestic violence in waiting rooms, other public areas, and in private areas including exam rooms and bathrooms
Small safety cards with information about safety planning and local advocacy services that can be hidden by a victim are available in several languages from the Family Violence Prevention Fund (phone: 415 252-8900; website: endabuse.org)
Having a private, sound-proof area where your conversation with a patient can not be overheard or creating as much distance as possible when screening a client who is accompanied by their partner
Examples of supportive messages to clients include:
	“It’s not your fault.”
	“You are not alone.” 
	 “You do not deserve to be treated this way.”
Educate clients about how abuse impacts many leading women’s health issues and how risk behaviors such as smoking and substance abuse can become coping strategies for women in abusive relationships

## Resources

**Family Violence Prevention Fund**
- _[http://www.endabuse.org/programs/healthcare/](http://www.endabuse.org/programs/healthcare/)_
**Mending the Sacred Hoop Technical Assistance **
- _[www.msh-ta.org](http://www.msh-ta.org/)_
**Sacred Circle**
- _[http://www.sacred-circle.com/](http://www.sacred-circle.com/)_
**American Medical Association**
- _[www.ama-assn.org/go/violence](http://www.ama-assn.org/go/violence)_
**Indian Health Service**
- _[http://www.ihs.gov/MedicalPrograms/MCH/V/index.cfm](http://www.ihs.gov/MedicalPrograms/MCH/V/index.cfm)_