Implementing a Universal Education Approach to Intimate Partner Violence in a Patient Centered Medical Home

Background: Intimate partner violence (IPV) is a serious, preventable health problem causing significant morbidity and mortality in the United States. Unfortunately, numerous barriers prevent healthcare settings from implementing focused screening and referral support for IPV services, as recommended by the US Preventative Services Task Force (USPSTF) (O’Doherty et al., 2015; Rees & Silove, 2014; Sprague et al, 2012; Rose et al., 2011; USPSTF, 2013). Evidence is growing for a universal education approach that overcomes many of the cited barriers by providing information about relationship health with patients, regardless of disclosure, and through increasing referral access to a community IPV advocate (Miller et al., 2011; Miller et al, 2013; Miller et al., 2015; Miller et al., 2017; Tancredi et al, 2015). Methods: This paper focuses on the implementation of this universal education approach in one patient centered medical home. Implementation was tracked through use of a QI/QA tool, counting referrals, and reviewing use of the protocol in the electronic health record. Effectiveness of training health care providers on the model was evaluated through surveys at set intervals: pre-training, immediate post training, and six months after training. Results: Results included self-reported changes in provider knowledge, confidence, and practice. Additionally, changes were demonstrated through referral numbers, disclosures, use of materials, use of the protocol, and collaboration with community partners. However, there were no statistically significant mean differences in reported behavior when comparing pre-training and six months follow up surveys. Conclusion: This evaluation adds support to a universal education approach to addressing intimate partner violence. Plans for integrating IPV advocate partners onto the healthcare team provide opportunity for further evaluation. IMPLEMENTING UNIVERSAL EDUCATION 3 Intimate partner violence (IPV) is a serious, preventable health problem causing significant morbidity and mortality in the United States. An “intimate partners” can be anyone whom someone has or has had a close personal relationship with, and IPV includes physical violence, sexual violence, stalking and psychological aggression (such as coercive acts and expressive aggression; Center for Disease Control [CDC], 2016). In their lifetime, at least one in four women and one in seven men report experiencing severe physical violence by an intimate partner (CDC, 2017). As many as one in three women and one in four men experience IPV including physical violence, sexual violence, or stalking, and nearly half of persons, of all genders, experience psychological aggression by a partner in their lifetime (CDC, 2011). IPV is an all too common problem. Extensive literature demonstrates the health impacts of IPV. Serious health consequences of IPV include, but are not limited to, increased rates of asthma, headaches, recurrent kidney infections, fibromyalgia, sexually transmitted infections, unintended pregnancy, medication noncompliance, anxiety, depression, suicidal behavior, injury, and death (CDC, 2015; Hampanda, 2016). More than half of all female homicide victims are killed by an intimate partner (Petrosky et al., 2017). An estimated 34% of IPV survivors who have injuries seek medical care for those injuries (Truman & Morgan, 2014), but many more are seeking care for commonly associated health issues without disclosing IPV. Persons who are experiencing IPV may not seek health care services specifically for disclosed IPV (Truman & Morgan, 2014), but they may be more likely to utilize healthcare services (Bonomi, Anderson, Rivara, & Thompson, 2009). Unfortunately, numerous barriers prevent healthcare settings from implementing focused screening for IPV and addressing the impact of intimate relationships on health. Public health advocates and primary care providers IMPLEMENTING UNIVERSAL EDUCATION 4 need an easily delivered, preventative approach to IPV that can impact population health and overcome barriers associated with traditional direct screening. An educational tool developed by Futures Without Violence (FWV) and funded by the Department of Health & Human Services (DHHS), provides primary prevention through education and awareness building. Research is demonstrating that this brief intervention in health care clinics is helping women leave unhealthy relationships, regardless of disclosure (Miller et al., 2011; Miller et al, 2017). The tool implements a universal education model, providing education about how healthy and unhealthy relationships impact health, along with information about resources. Universal education is a process that normalizes conversations about IPV and provides information to all, not just those who are suspected of or disclose experiencing IPV. Review of Literature