# Presentation: 717367

## Domestic Violence

- DONALD CLARK MD MPH
- Medical Epidemiologist
- Albuquerque Area Southwest Tribal Epidemiology Center
- Rachel Locker MD
- Warm Springs Health and Wellness Center , Warm Springs OR

**Screening and **
**Documentation **

## Domestic Violence Is A:

*Pattern* of assaultive and coercive behaviors
- Physical, sexual, and psychological and economic
- That *adults or adolescents* use against their intimate partners or former partners.** **

**Notes:**
This module deals with Intimate Partner Violence, not child abuse or elder abuse.
This is the definition taught by the Fund. 
A credible threat of physical or sexual violence is usually necessary to enforce the other forms of abuse.

## Domestic Violence:

- Chronic “disease” with acute exacerbations

**Notes:**
The victim of domestic violence is not responsible for starting or stopping the abuse, and in this sense is not “diseased”. But domestic violence can be compared to a chronic disease like diabetes or alcoholism, with variable periods of relative calm punctuated by more serious episodes of violence. Many providers are under the impression that domestic violence is only a problem at these times. Screening for domestic violence in the primary care setting is not only appropriate, but may provide a less stressful time and place for the patient to disclose this important aspect of her health. These visits may also offer more opportunities than visits for acute injuries to talk with patient without the abuser waiting. 
Whether we recognize DV or not, we see victims every day in all varieties of health care presentations and settings.

## Injuries Often Seen 

- Head and neck
- “Swimsuit” distribution
- Multiple sites
- Different stages of healing
- Inconsistent w/ reported mechanism of injury
- Delayed care

**Notes:**
We are used to thinking of DV in terms of physical injuries. It is true that not all women with these patterns of injury are victims of abuse. But it is equally true that we will not recognize many victims if we screen only those women who present with these patterns of injuries. 
Injuries to the head and neck are common, as are those in areas usually covered by clothing. Injuries in different sites in different stages of healing are very suggestive, just as they are for child abuse when noted on a child. Also similar to child abuse – injuries where the reported history just doesn’t make sense, or when care is delayed beyond the time a reasonable person would have waited.

## Medical Presentations

- Higher levels of smoking
- Chronic pain syndromes (GI, joint, chest, back, abdomen and pelvis)
- “Noncompliant”
- “Uncontrolled ____ “(fill in blank)

**Notes:**
Again a reminder that not every woman with these conditions is a victim of domestic violence, and many victims will not be identified if we screen only women with these presentations. These are patients whom we may question more carefully, or screen more frequently. 
Think of noncompliance as a symptom, not a disease. Many women may not be allowed to comply with your treatment recommendations because of the perpetrator’s demands. E.g. a diabetic may not comply with her exercise regimen because she cannot leave the house. A depressed patient repeatedly “loses” her SSRI and does not keep appointments in behavioral health because the perpetrator does not allow her to come to the hospital.
In addition, a compliant patient’s illness may become uncontrolled  due to increasing domestic violence. For example, we must consider infection as a possible cause of out of control blood sugars, but we should not forget to consider DV, too.

## Psychiatric Presentations

- Less favorable impression of physical and mental health status
- Nonconsensual sex
- Depression

**Notes:**
All of these conditions are more likely to occur in victims of domestic violence.

## Psychiatric Presentations

- Generalized anxiety
- Depression
- PTSD
- Substance abuse

**Notes:**
All of these conditions are more likely to occur in victims of domestic violence.

## GYN Manifestations

- Sexual dysfunction
- Dyspareunia
- Recurrent UTI’s
- STI’s
- Chronic pelvic pain

**Notes:**
Pressure to have sexual intercourse, with or without threats of violence or rape. 
Abusers may place victims at risk by refusing to use condoms.

## OB Manifestations

- Late and intermittent prenatal care
- SAB and low birth weight babies
- Placental separation
- Antepartum hemorrhage
- Fetal fracture
- Preterm labor

**Notes:**
Homicide is the most common cause of death in women who are pregnant and during the postpartum period. It is more common than other causes of prenatal M&M. Not all these homicides are a result of DV. But by one estimate half of these deaths are due to DV.

## More abuse = more symptoms

- Medical Presentations

**Notes:**
The worse the abuse, the more symptoms and the more severe the symptoms. This has been shown to be the case for women with any or all of the presentations shown.

## Homicide

- _Female homicides in NM:_
- 4.9 per 100,000 Native American women
- 1.8 non-Hispanic white women
- 1.7 for Hispanic women

**Notes:**
Death is obviously the most serious consequence of domestic violence. Native women in NM were murdered at a much higher per capita rate than white and Hispanic women. 

## Female Homicides in NM

- DV was the cause in 46% of Native American Female Homicides

## Oregon Statistics

- 1997-2001 Review of Intimate Partner homicides
- 151 women murdered
- 50%  (n=75) murdered by intimate partner
- 387 men murdered
- 4% (n=17) murdered by and intimate partner
- 29 % (n=5 )of those killed in self defense

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## Kids – The “Forgotten Victims”

- “Intervention” injuries
- Bystander injuries
- Injuries to child to control mother’s behavior or hurt her
- Direct and intentional child abuse

**Notes:**
Children can also be the victims of domestic violence in several ways:
They may be injured while trying to protect their mothers, i.e. when pulling Daddy of Mom.
They may be innocent bystanders, e.g. shot while abuser was trying to shoot mother.
Threats to hurt the child may be used to control or hurt the mother.
There is an enormous overlap between domestic violence and child abuse of about 50% - that is any home with domestic violence and children has about a 50% chance of also having child abuse.

## Kids – The “Forgotten Victims”

- Custody disputes
- Long-term cognitive, behavioral and psychological effects

**Notes:**
Threats of custody disputes are a common way to control a woman’s behavior. 
The long-term effects on a child a partly due to the child’s developmental age at the time of the abuse. Difficulties with attachment, with concentration in school, and with impulse control all occur. 

## Adverse Childhood Experiences (ACE) Study

- The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences
- Survey of adults in CA HMO
- (n=9,508 adults; response rate=70.5%)

**Notes:**

This landmark study has led to a series of publications that address many leading public health issues

 For a comprehensive listing of current publications, run a search in Medline or a similar database using the key words, “Adverse Childhood Experiences.”

## Adverse Childhood Experiences

- Growing up with domestic violence
- A parent with a substance abuse problem
- A parent with a history of mental illness
- A parent with a history of criminal  behavior
- Childhood abuse and neglect

## Prevalence of ACEs

_**Household exposures**_**:****	****	****	****    **_** (%)**_
**Alcohol abuse****	****	****	****	****    23.5**
**Mental illness****	****	****	****	****    18.8**
**Battered mother****	****	****	****	****    12.5**
**Drug abuse ****	****	****	****	**** ****	****      4.9**
**Criminal behavior  ****	****	****	****  ****	****      3.4**
_**Childhood Abuse**_**:**
**Psychological****	****	****               ****	****    11.0**
**Physical****	****	****	****	****  ****	****    10.8**
**Sexual****	****	****	****	****   ****	****    22.0**

## ACEs have a graded relationship with:

- Ischemic heart disease
- Cancer
- Chronic lung disease
- Skeletal fractures
- Liver disease

## Childhood Exposure to Domestic Violence 

**↑ ****#** ACEs
- Positive, graded risk for:
- 		- **Illicit drug use**
- 		-** IV drug use**
**	****	**- **Depression**
**More Exposure = More Problems**

**Notes:**

A positive grade risk means that as the frequency of witnessing domestic violence increased, the risk of experiencing alcoholism, illicit drug use, IV drug use and depression also increases

Screening for lifetime exposure to as well as current victimization is critical to clients’ long-term health

“These findings make a strong case for comprehensive screening for lifetime experience of abuse in multiple setting due to the long-term and far-reaching health implications of growing up in a home with domestic violence”

-Debbie Lee
Family Violence Prevention Fund

## Persons with 4+ ACEs had 2-4 fold risk for:

- Smoking
- Poor self-rated health
- Having 50 or more sexual intercourse partners
- Sexually transmitted diseases

## Persons with 4+ ACEs had 4-12X ↑ risk for:

- Alcoholism
- Drug abuse
- Depression
- Suicide attempts

## Guiding Principles

- Become advocates for victims and their children
- Change the health care  system to better respond to domestic violence

## Effective Response =Changes In:

- Screening for DV
- Assessment
- Intervention
- Documentation

**Notes:**
Effective response to DV in your clinic or office may require changes in all these areas. 

## Why Screen?

- DV screening is 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!

## Why Screen?

- 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

## GPRA

- Government Performance and Results Act *– federal law*
- Performance-based budgeting
- Measurable performance indicators to demonstrate effectiveness in meeting Agency mission

## GPRA

- Government Performance and Results Act *– federal law* captures:
- Screening intentional *attempts*
- Diagnoses
- Patient education codes

## Clinical Objectives

- Adult females should be screened for DV at the initial encounter and then at least annually
- Prenatal patients should be screened once each trimester

## Barriers To Screening 

- Personal Experience
- Brings up memories
- Staff may not be ready to deal with  past or present personal experiences
- Misconceptions and misinformation

## Barriers

- “I Can’t fix it”
- In medicine we are used to providing a test, a pill or something to resolve the problem
- DV is not so easy

## Barriers

- Open “Pandora’s box”
- Fear that not enough time is allowed if this patient opens up
- “ I don’t know what to do if she says yes”
- Confusion about mandatory reporting
- Competing public health agenda

## Addressing barriers

- It is not your job to “ fix it”
- Provide information/ education
- Offer to call an Advocate
- Assess Safety/ lethality
- Document- screening, injuries, health effects

## Foundations

- Provider Education is a must
- Health Effects
- How to screen and document
- What to say /What **not **to say
- Referral resources
- Administrative support is needed

## Power and Control vs. Advocacy 

**Advocacy**

- Trivialize the abuse **or **Believe and validate her experiences

-  Blame the victim **or **Acknowledge
- injustice

- Try to force your choices **or** Respect her autonomy

- Ignore the need for safety **or **Help her plan for future safety

- Fail to respond to her disclosure or promote access to community services

- Violate **or **Respect Confidentiality

**Notes:**
Note difference in how wecan be advocate of  demonstrate power over the patent.

Give examples 

## IHS/ACF DV Pilot Project

- Developed in 2002 to work with Indian/Tribal/Urban healthcare facilities
- Create collaboration between clinics and DV advocates
- 15 IHS/Tribal and Urban healthcare sites

**Notes:**
*The FVPF had first piloted hospital-based reform in California, New Mexico, & Pennsylvania and the model was then expanded to work closely with 10 states, but  the FVPF had not yet worked specifically with Native communities until this project. 

## IHS/ACF DV Pilot Project

- Faculty: Family Violence Prevention Fund
-  Sacred Circle
-  Mending the Sacred Hoop
- Funders: Indian Health Service,
-    Administration for Children and Families

**Notes:**
*The FVPF had first piloted hospital-based reform in California, New Mexico, & Pennsylvania and the model was then expanded to work closely with 10 states, but  the FVPF had not yet worked specifically with Native communities until this project. 

## Participants 2002 

- Ketchikan Indian Corporation Tribal Health Clinic (Ketchikan, Alaska)
- Houlton Band of Maliseet Indians (Houlton, ME)
- Warm Springs Health & Wellness Center (Warm Springs, OR)
- Crownpoint Healthcare Facility/Family Harmony Project (Crownpoint, NM)

**Notes:**
These participants are mentors to all of you.  You may contact any of these teams to learn more about the work they’re doing in their communities.  Some clinic are tribal-run, two are urban (UAII in Los Angeles and NATIVE Project in Spokane, WA) and others are Indian Health Service facilities. 

## Participants 2002 

- 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)

**Notes:**
These participants are mentors to all of you.  You may contact any of these teams to learn more about the work they’re doing in their communities.  Some clinic are tribal-run, two are urban (UAII in Los Angeles and NATIVE Project in Spokane, WA) and others are Indian Health Service facilities. 

## Participating Sites: added  Phase 2

- 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)

## Domestic ViolenceGPRA Clinical Performance Measure

- FY 2005
- The IHS will ensure that 14% of women between the ages of 15 and 40 are screened for domestic violence.
- FY 2006
- The domestic violence screening rate in female patients ages 15-40 will increase.
- FY 2007** **
- Maintain @ ’06 rate of 28%
- IHS 2010 goal for DV Screening
-  40% for female patients ages 15-40

**Notes:**
(I don’t think the 2005 goal is accurate- the 2004 result was 4% and the 2005 goal was to maintain. The 2004 target was 15%)

## GPRA IPV/DV Measure Results

- National Average GY2004
- 4%
- National Average GY2005
- 13%
- National Average GY2006
- 28%

## IHS-ACF DV Pilot Project 

- GY2006 Results
- Data from 14 of 15 sites
- 13 of 15 exceed 2006 target of 14%
- 7 sites exceed 2010 target of 40%

## Documentation in RPMS

- Conducted as and “Exam “
- Documented  as
- Normal/negative- denies past or present DV
- Present – acknowledge in the past 12 mo
- Past-  > 12 months ago
- Refused – declined exam
- Unable to screen
- Entered as Exam code #34

## Provider Documentation (cont’d)

- Results can also be recorded by using a stamp on the PCC form, or
- Customized PCC+ template
- Sample PCC+ text box below:

| DV/IPV Exam Screening (circle one) |  |  |  |  |
| --- | --- | --- | --- | --- |
| Negative | Present | Past | Refused | Unable to screen |
| Comment |  |  |  |  |
|  |  |  |  |  |

## Electronic Record

- Reminders improve providers  memories
- Easier documentation – one place only