# Presentation: 028015

## INDIAN  HEALTH  SERVICE  ANDOFFICE  FOR  VICTIMS  OF  CRIMECHILD  ABUSE  PROJECTPAST,  PRESENT,  AND  FUTURE

**CDR P. Jane Powers APRN, BC, MS, FAANP**
**Project Director**
**SEPTEMBER  2004 PRESENTATION TO INDIAN HEALTH SERVICE AND OFFICE FOR VICTIMS OF CRIME**
**WASHINGTON, DC**

## SPECIAL THANKS AND APPRECIATION

**Cathy Sanders, Acting Director, Federal Crime Victims Division, Office for Victims of Crime**
**Al Hiat, PhD (Retired), Behavioral Health Consultant, Indian Health Service Headquarters East**
**Indian Health Service Headquarters East:**
**        ****- Richard Olson, MD, Acting Director, OCPS**
**        ****- Judith Thierry, DO, Maternal Child Health Coordinator   **
**        ****- Ramona Williams, Social Worker**
**Paulette Hansen, Director, American Indian Information Network**
**Project Faculty**
**Second Opinion Software, LLC**
**Project Making Medicine, University of Oklahoma**
**U&O Service Unit**

## WHAT  IS  CHILD  ABUSE  AND  WHAT  DOES  IT  LOOK  LIKE  IN  INDIAN  COUNTRY?

**Definition can range from “intentional inflicted injury” to **
**    “****any act that impairs the developmental potential of a child”.**
**Included in this definition are neglect (acts of omission) and physical, psychological, or sexual injury (acts of commission) by a parent or caregiver.**
**Nationally, physical abuse (18.6% of reports) occurs more frequently than sexual abuse (9.6%) but is not as often reported (DHHS, 2001).**
**                                                                                         ****continued . . .**

**American Indians/Alaska Natives compose 2% of reported victims (DHHS, 2001).**
**Few statistics exist – most are general statistics, few are Tribal or Reservation specific, not tracked the same by each site or organization**
**In 1999, a National Indian Justice Center film “Bitter Earth:  Child Sexual Abuse in Indian Country” estimated that 1 in every 4 girls and 1 in every 7 boys are victims by age 18.**
**In 2002, the National Child Abuse and Neglect Data Systems (Department of Health and Human Services) reported victimization rates of 21.7 cases per 1,000   children living in Indian Country (10.7 for Whites, 9.5 for Hispanics, 20.2 for Blacks).**
**                                                                                        ****continued . . .**

##  In 2000, A Tribal survey done by the Casey Family        Programs Foundation for the Future and the National        Indian Child Welfare Association estimated that in Indian     Country:         - That only 61% of child abuse cases are reported         -  Over 80% of responding Tribes had a Child Protection              Team (CPT) and protocols in place         -  50% operated their own social and police services         -  Only 23% of Tribes managed their own cases         -  33% relied on others with no Tribal input         -  2% contracted for these services                                                                 continued . . .

##          -   Remaining 42% of Tribes worked with individual                 states (20%), counties (11%), Bureau of Indian                 Affairs (7%), and Tribal Consortiums (4%).            -  42% of Tribes included IHS as a CPT member but                at the same time 77% claimed lack of access for                medical provider examinations                     -  17.5% of Tribes used a local hospital                     -  7% used a local doctor                     -  3.5% used a specialist

**PROJECT  HISTORY**
**Is a coordinated effort between Indian Health Service and Office for Victims of Crime to provide training and resources in the medical evaluation of child maltreatment to physicians, nurse practitioners, and physicians assistants who care for Native American/Alaskan Native children**
**Evolved from a successful pilot project at the Ft. Duchesne Indian Health Center in Utah (Northern Ute Reservation)**
**Began in 2000 and has to date received approximately $414,000 in operational funding from Office for Victims of Crime **
**OVC funds expire 12/31/04; IHS Headquarters provided $286K for project operation for 2005-2006**
**Open to Tribal and IHS providers**
**Same model of care used by the state of Utah’s **
**     ****Children’s Advocacy Centers (also patterned after the**
**     ****Ft. Duchesne project)**

## COURSE  REQUIREMENTS

**Is a two year training commitment**
**Prospective participants must submit with the application**
**      ****(beginning with the October 2003 class):**
**          ****- What hardware/software is available to them**
**          ****- Letter of intent to participate that includes a     **
**            ****commitment to stay at their present position   **
**            ****for the duration of the course**
**          ****- Letter of support for their participation from    **
**            ****the facility director, immediate supervisor**
**          ****- CV and current license**
**                                                                                ****continued . . .**

##  Year One –      - One week intensive didactic/classroom training with          37.25-44.7 CME’s provided (November 2000, October 2003)     - Needed hardware/software purchased for each site for                        photodocumentation of clinical findings and the         establishment of the telemedicine link for consultation         and peer review      - One week preceptorship with national expert faculty of            their choice (hands on clinical and mentoring         experience (35-42 CME’s provided)     - Participants conduct medical examinations of child         victims of abuse with photodocumentation                                                                                   continued . . .      

##     - Sites establish telemedicine link with base (computers of            participant and Project Director are able to transfer data        with Second Opinion software)    - All cases conducted by participants with specific data sent        to Project Director for consultation, peer review, teaching        via software provided    - National expert consultation available as determined by        Project Director                                                                                       continued . . .

##  Year Two –     - Participant photodocumentation skills perfected     - One week advanced preceptorship with national expert         faculty of their choice (hands on clinical experience with         focus on case interpretation as a consultant; 35 CME’s         provided for physicians, 42 for nurses)     - All cases conducted by participants sent to Project         Director for consultation, peer review, teaching via         software provided     - Development and implementation of site specific policies         and procedures for service                                                                                        continued . . .

##     - Participation in monthly Grand Rounds (peer review, one        CME provided)    - Site visit by Project Director     - Certificate of Excellence Award (plaque) upon successful        completion of both years of training    - Encouraged to be “expert” for local geographic area    - Encouraged to develop and/or participate in the local MDT/CPT    - Attend at least one national child abuse conference with a        specific medical track on a yearly basis    - All IHS/OVC Child Abuse Project resources still available        to all those who have successfully completed the        course

## PROJECT  GOALS

**(1)  To provide equipment, training, and resources to medical   providers within the Indian Health Service and Tribal programs on the medical evaluation of child maltreatment**
**(2)  To create a database of statistics on child abuse and neglect in Indian Country including Alaskan Natives**
**(3)  To create an infrastructure of experts in the field of child maltreatment within Indian Country including Alaskan Natives to locally serve child victims and their families**
**(4)  To create an ongoing system of resources in this field in  Indian Country including Alaskan Natives for medical  providers**
**(5)  To create a mechanism of peer review and quality  improvement for services provided to Native child           victims of maltreatment            **

## PROJECT  PARTICIPANTS

**November 2000 Class:**
**         ****- Alaska: **
**              ****Bethel - Participant: Jennifer DeLeon, MD **
**                          ****- Status: ****Completed 2004 ****but leaving 11/04            **
**                          ****- Project purchased 35 mm camera with flash to fit **
**                            ****their colposcope, software, scanner **
**              ****Dillingham - Participant: Jackie Tindall, FNP**
**                                 ****- Status: Resigned position in 2001, no one **
**                                   ****designated to continue project**
**                                 ****- Project purchased software and scanner  **
**              ****Kotzebue - Participant: Janet Shackles, MD**
**                               ****- Status: Resigned position in 2001; Pam **
**                                 ****Grimaldi, MD, designated to continue**
**                               ****- Project purchased software, colposcope          **
**                                 ****and camera, scanner      **
**                                                                                        ****continued . . .**
**           **

##          Juneau - Participant: Mark Peterson, MD (SEARHC)                          - Status: Completed 2004                          - Equipment/software at Child Advocacy Center     - Arizona:            Whiteriver - Participant: Janelle Brown, MD                               - Status: Completed 2004                              - Project purchased colposcope with camera,                                 scanner, software           Tuba City - Mary Jo Parys, FNP                             - Status: Will complete 2004                            - Project purchased colposcope with camera,                               scanner, software           San Carlos - Participant: Sharon Wattley, MD                                - Status: Resigned position before year 1                                  preceptorship, no one designated to                                                              continue project                               - Project purchased colposcope with camera,                                  scanner, software, modem                                                                                          continued . . .

##          Gila River - Participant: Adelaide Bahr, MD                               - Status: Decided not to participate as this was                                 not a priority for the service unit                              - Project purchased colposcope with camera,                                 scanner, software, modem     - New Mexico:            ACL Hospital - Participant: Nelly Wolff, MD                                   - Status: Resigned position after end of first                                      year, no one designated to continue project                                  - Project purchased colposcope with camera,                                     scanner, software      - Montana:            Ft. Belknap - Participant: Dennis Callendar, MD                                - Status: After initial training, the service                                         unit decided to refer all child abuse                                             cases to Great Falls                                - Project purchased no equipment for this site                                                                                               continued . . .

##            Ft. Peck - Participant: Peggy O’Hara, MD                          - Status: Resigned position shortly after initial                             training; site requested to send another provider                             to next course but they did not                          - Project purchased colposcope and camera,                             software             Crow Agency - Participant: Lori Byron, MD                                    - Status: Decided not to continue after year 1                                       as she felt she already knew the material                                    - Project purchased colposcope and camera,                                       teaching tube, software                          Northern Cheyenne - Sharon Plotke, MD, and Melissa                                                  Broomhall, MD                                               - Status:  Both resigned within a                                                       year; Dave Freeman, FNP,                                                    designated to continue                                               - Project purchased colposcope                                                        and camera, software, scanner                                                                                       continued . . .

## - Wyoming:                                                                                          Ft. Washakie - Jackie Nelson, MD                              - Status: Completed 2004                              - Project purchased scanner and software                                                 SUMMARY

**2000 Class – Completed**
**Bethel, Alaska**
**Juneau, Alaska**
**Whiteriver, Arizona**
**Tuba City, Arizona**
**Ft. Washakie, Wyoming**
** *****Will receive plaque and new edition of software –**
**     ****query and forensic form**

**2000 Class – Still Participating**
**Northern Cheyenne, Montana**
**Kotzebue, Alaska**** **

##   October 2003 Class:         - Alaska:                Bethel - Susanna Block, MD, and Amy Strnad, MD                            - Status: Dr. Block has completed year 1 but is                               resigning; Dr. Strnad took the summer off and                               the site would not pay for year 1 preceptorship,                               she may be leaving also; waiting to test                               telemedicine connection                            - Project purchased no new equipment since 2000                Kotzebue - Pam Grimaldi, DO                                 - Status:  Completed year 1 but telemedicine                                    connection not functional                                     - Project purchased no equipment since 2000                Juneau - Amy Dressel, MD                              - Status: Completed year 1                              - Project purchased no equipment for site;                                 funded CAC by Catholic Community Services;                                 telemedicine connection functioning                                                                       continued . . .                                                                             

##          - Montana:                Northern Cheyenne - Dave Freeman, FNP                                                 - Status: Completed year 1                                                  - Project purchased no new equipment                                                                                                         since 2000, telemedicine connection                                                    functional         - Oklahoma:                 Clinton - Dolly Garcia, MD                              - Status:  Completed year 1, telemedicine                                 connection not functional                                  - Project purchased video camera, software         - North Dakota:                  Belcourt - Pam Kidd, MD, and Kathleen Hughes-Kuda, MD                                    (gynecologist = exam, psychiatrist = interview)                                 - Status: Both completed year 1                                  - Project purchased video camera, software;                                                   telemedicine connection functioning                                                                                        continued . . .                                                                             

##          - South Dakota:                Fort Thompson - Renette Kroupa, PA-C                                            - Status: Completed year 1                                             - Project purchased no equipment for                                               this site; telemedicine connection                                               functional                Wagner - Gretchen Esplund, MD                              - Status:  Not completed year 1 due to staffing at                                 her site, telemedicine connection not functional                                  - Project purchased video camera, software;                                telemedicine connection not functional                 Sisseton - Lois Crawford, MD                                - Status: Completed year 1                                 - Project purchased video camera, software;                                                   telemedicine connection functioning                                                                                                                                                                                                                                                                         continued . . .                                                                             

##          - Michigan:                Keweenaw Bay - Teresa Frankovich, MD                                           - Status: Completed year 1                                            - Project purchased video camera, soft-                                             ware; telemedicine connection not                                              functional                Sault Ste. Marie - Vivica Fitzpatrick-Sherman, MD                                            - Status:  Completed year 1, telemedicine                                               connection not functional                                                - Project purchased video camera and                                               software         - New Mexico:                 Shiprock - Karen Cook, FNP                                - Status: Completed year 1                                 - Project purchased digital camera for existing                                   colposcope, software; telemedicine                                   connection functioning                                                                                                                                                                                                   continued . . .                                                                             

##                                   Pine Hill - Jean Proper, FNP                               - Status: Completed year 1                                - Project purchased video camera, software;                                  telemedicine connection not functional                Gallup - John Ratmeyer, MD                            - Status:  Completed year 1                            - Project purchased video camera, software;                              telemedicine connection not functional                                                                                                                                                               

**SUMMARY**
**Participants who have dropped out of project to date:**
**Bethel – Susanna Block, MD**
**                          ****Amy Carson-Strnad, MD ?**

## PARTNERSHIPS

**November 2000 Class – Boise, Idaho**
**        ****- American Indian Information Network in Albuquerque **
**         ****provided all course materials, equipment rental, faculty **
**           ****travel/fees, transportation, food ($35,000)**
**        ****- CARES Unit, St. Luke’s Regional Medical Center, Boise, **
**           ****Idaho, provided staff, secretarial support, training facility**
**           ****(approximately $10,000)**
**        ****- Cultural component (Navajo) provided by Robbie**
**           ****Daniels, Gallup, New Mexico**
**                                                                            ****continued . . .**
**       **

**October 2003 Class – Oklahoma City, Oklahoma**
**        ****- Project Making Medicine (University of Oklahoma) **
**           ****provided all course materials, some student/faculty             **
**           ****correspondence, travel/hotel for nonIHS students, **
**           ****training facility, transportation, food, coordination of     **
**           ****activities, clerical support, speakers, other ($25,000)**
**        ****- Cultural component (Cheyenne) provided by Project **
**           ****Making Medicine **
**2005 Class – Month and date not yet determined**
**        ****- University of Utah perhaps**
**        ****- Cultural component (perhaps Ute, Paiute, **
**           ****Goshute, Shoshone, or other local Tribe)**
**                                                                            ****       **

## PERMANENT  EXPERT  FACULTY

**P. Jane Powers APRN, BC, MS, FAANP (Project Director)**
**Jay M. Whitworth, MD (Jacksonville, Florida)**
**Robert W. Block, MD (University of Oklahoma)**
**Astrid Heger, MD (Los Angeles County/University of Southern California Medical Center)**
**Carolyn Levitt, MD (Midwest Regional Children’s Advocacy Center)**
**Rich Kaplan, MD (Midwest Regional Children’s Advocacy Center)**
**Joyce Adams, MD (University of California – San Diego)**
**Lori Frasier, MD (Primary Children’s Medical Center, Salt                Lake City)**
**Deborah Lowen, MD (University of Oklahoma)**
**Renee Ornelas, MD (University of New Mexico)**
**Sites for clinical preceptorship training.**

## PROJECT  EVALUATION

**Were program goals met?**
**     ****(1)  To provide equipment, training, and resources **
**     ****(2)  To create a database of child abuse statistics **
**     ****(3)  To create an infrastructure of experts in Indian Country **
**     ****(4)  To create an ongoing system of resources **
**     ****(5)  To create a peer review/quality improvement mechanism **
**Didactic (classroom) training evaluation (handout)**
**Preceptorship evaluation**
**Outcome evaluation – via Site Specific Data, still in progress**
**Site visits – comments from MDT/CPT members,          supervisor, participant           **

## PROJECT  ACCOMPLISHMENTS

**The number, variety, caliber, and commitment of the national experts **
**        ****- No other existing child abuse program has this many of the **
**          ****nationally recognized experts on their faculty**
**        ****- These are the experts who are conducting the research in the **
**          ****current literature that guides current practice**
**Commitment of participants**
**National program publicity and recognition in Indian Country and the number of providers who want to participate**
**The elevation and standardization of the quality of medical care provided to AI/AN child victims of abuse (best practices)**
**The collection of case statistics for each participating site begins a national database for Indian Country**
**                                                                                     ****continued . . .**

**The collection of child abuse cases (photographs) from participating sites begins a one of a kind national library of   such data**
**Is an example of a successful partnership between two**
**     ****federal agencies for the improvement of care/services to**
**     ****AI/AN**
**Project listserv – in progress**
**Web site – **_[http://www.ovccap.ihs.gov](http://www.ovccap.ihs.gov/)_
**Whiteriver site already seeing child abuse case referrals from San Carlos, elsewhere **
**Interest from a nonprofit organization in Bangkok, Thailand, in implementing same type of program in slums**
**Program nominated for an award from APSAC (not**
**     ****successful)**
**Letters sent through a private citizen for a congressional**
**     ****appropriation for funding**
**Program Assistant hired August 2004**

## PROJECT  BUDGET

**SEE  HANDOUTS**

## PROBLEM  AREAS

**Staffing levels – most participating sites are short staffed on medical providers which has delayed project activity completion**
**Tech support – delayed, not a priority for the department**
**      ****- Has delayed telemedicine hookup, thus case review and **
**        ****participation in Grand Rounds**
**Participant completion of case and site specific data forms**
**Funding secured on a short term basis only, need long term ongoing funding – request to federal agencies, congressional request**
**Most significant problem is that IHS/Tribes have no uniform  case tracking mechanism:**
**         ****- Examples**
**         ****- Statistics from sites not reliable**
**         ****- What is the extent of child abuse in Indian Country?**

## FUTURE  PLANS

**Continued pursuit of more permanent, long term funding; including partnership with University of Utah (private sector funding possibilities such as Robert Wood Johnson, other)**
**Pursuit of additional funding for 2005-6 to increase number of participants, provision of equipment, full time assistant**
**Computerized learning modules for didactic training**
**       ****- Problem is too much content/activities packed into 5 full days **
**         ****of classroom (didactic) training but all are important**
**       ****- Participants complete modules (lectures with quiz) at their **
**         ****own pace BEFORE scheduled didactic training**
**       ****- Summary/discussion of topics only at didactic training**
**                                                                                              ****continued . . .**

**To motivate support for the development and implementation of an IHS-wide (including BIA, FBI, Tribes) uniform child abuse case tracking mechanism for obtaining accurate and meaningful statistics (NICWA pilot project)**
**Specific standardized IHS form for documenting the medical examination for suspected child abuse **
**Utilization of “real time” software technology when needed**
**     ****(example – Bethel)**
**Merge programs for adult and child sexual assault into a single holistic approach – victimization across the life span**

**END**