From Warm Handoff to Wrap-Around Care: Role of a Digital Warm Handoff in Improving Emergency Department Care for Domestic Violence Survivors

Domestic violence represents a pervasive social problem. According to recent national estimates, one in four women and one in ten men will be harmed by a current or former intimate partner, and many more will be harmed by another cohabitant or family member (1). Often these survivors visit emergency departments to seek help, yet few actually receive support beyond the cursory treatment of their injuries. Even emergency department interventions intended to help survivors, such as universal screening and referral or educational information, typically fail to give survivors the support they need. In recent years, two types of intervention have transformed domestic violence care in some emergency departments. First, eHealth interventions based in digital technology have streamlined and transformed domestic violence care within emergency departments. While digital technology is not a panacea for the challenges emergency departments face in providing domestic violence care, providers are accepting of eHealth interventions, and they appear to facilitate effective care. Second, warm handoff interventions, originally developed for use in other areas of medicine, allow providers to connect survivors directly with a named domestic violence advocate. This approach offers a continuity of care to survivors that limited evidence suggests is likely to support their wellbeing and access to services. In 2014, a Level 1 trauma center in a large metropolitan California county implemented an eHealth intervention called Domestic Violence Report and Referral (DVRR) that facilitated a warm handoff to advocacy services -- among the first interventions to integrate these two intervention styles. In 2016, two additional private hospitals in the same county implemented the intervention. This dissertation tracks the outcomes of DVRR implementation. Paper 1 estimates the likely causal effect of the intervention on the referrals and local advocacy services survivors received; Paper 2 investigates whether those outcomes varied by race, ethnicity and gender; and Paper 3 explores providers’ views on the impact DVRR had on their care of domestic violence survivors. In Paper 1, I conducted this causal analysis within a multiple baseline design. It included 2292 medical records, reflecting 45-62 months of survivors’ emergency department visits at each of the three study hospitals. Findings in this paper suggest that DVRR was associated with an increase of 2.55 (95% CI: 2.13-3.05) to 6.16 (95% CI: 2.93-12.95) times in survivors’ likelihood of connection to advocacy, and that this association was likely caused by providers using DVRR. In Paper 2, I further analyzed 1366 medical records from Hospital 1, using multiple regression to explore the impact of DVRR by race/ethnicity and gender. This analysis suggested that DVRR was particularly impactful for Black survivors, who averaged 4.66 times higher odds of connection to advocacy with DVRR administration(p<0.01), and men, who averaged 12.80 times higher odds of connection to advocacy with DVRR administration (p<0.01). Latinx, white and female survivors experienced 2.60 increase in odds of advocacy when DVRR was administered. The resulting 43.03% of Latinx survivors who reached advocacy represented the highest proportion of any group. In Paper 3, ten medical and ten social service providers at two hospitals participated in semi-structured interviews about the impact of DVRR on the domestic violence care they offered to survivors in the emergency department. Emergent themes suggest that providers welcome many features of DVRR, such as its direct connection to advocacy and the provider support offered through its structured nature. However, in addition to minor technical problems, they noticed gaps in inclusivity, particularly for non-English speakers and transgender and nonbinary survivors, that affected their ability and interest in DVRR to care for all survivors. Taken together, the findings from these analyses suggest that, while imperfect, DVRR appears to improve DV care and connection to advocacy for the participants in this study. This lends support to eHealth delivery of positive interventions, and the promise of warm-handoffs as an intervention strategy that improves supportive care for survivors of domestic violence.

Advisor: Manchikanti Gomez, Anupama