**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Special Populations: Homeless Veterans and Veterans Experiencing Intimate Partner Violence**

**Presented by:  Sonya Gabrielian, MD, MPH, and Melissa E. Dichter, PhD, MSW**

**November 20, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact at**Sonya.Gabrielian@va.gov**or Melissa.Dichter@va.gov.*

Moderator:We are at the top of the hour so at this time I would like to introduce our speakers. Speaking first we have Dr. Sonya Gabrielian, I’m sorry I totally butchered that. She works at the Mental Illness Research Education and Clinical Center and UCLA Department of Psychiatry and Behavioral Sciences at the VA in Los Angeles. Joining her today is Dr. Melissa Dichter she is a core investigator and Career Development Awardee at the VA HSR&D Center for Healthy Equity Research and Promotion at the Philadelphia VA Medical Center. So we’re very thankful to have our presenters joining us today. At this time I’d like to turn it over to Sonya.

Dr. Gabrielian: Thanks so much Molly. Let me see if I can get our slides to advance here. So I’m happy to be here virtually with all of you today. I’m talking about a quality improvement project that we’ve been quite excited about. This is a collaboration between the Homeless PACT’s here at the VA Greater Los Angeles, as well as, the VA Pittsburgh and the Birmingham VA. I’d like to tell you a little bit about the work we’ve been doing. I’d like to give a special acknowledgement to all my co-authors here especially Dr’s Adam Gordon and Lillian Gelberg and Stefan Kertesz who have really been the leader forward. So I’ll start off by giving a little bit of background information about homeless adults, primary care, the intersection between these two domains and move from there into an introduction of Homeless Patient-Aligned Care Teams, the Homeless PACT’s that probably many of you are already familiar with. From there we’re going to lead into a case study of our three Homeless PACT’s of those three sites that I mentioned. We’ll start off by talking about the structures of each of these Homeless PACT’s. Move into the initial cohorts of patients seen in each of these patient-aligned care teams and finish up with some utilization patterns that we see within these VA patients cohorts, both at that time that they enter the pact, as well as, at six month follow up and I’ll finish up with some conclusions and implications before we move onto the second half of the talk. 

So first we have a poll question. I think Molly takes over here—just to get a little bit of information about all of your expertise in this area.

Moderator:Right thank you. So as you can see up on your screen that you have the question: Which of the following best describes your work homeless Veterans? The answer choices are: I am a clinician who sees homeless Veterans in practice; I’m a researcher who studies homeless Veterans; I am a policymaker/administer involved in services for homeless Veterans; I work with homeless Veterans in some other capacity; and I do not work with homeless Veterans. So it looks like a fair portion of our audience has answered and we have right around 38% who sees Veterans in practice...

[background voice]

Moderator:Excuse me. Your line is un-muted. Can you please press mute.

Unidentified Female: Sorry I’m muting it now.

Moderator:Thank you. We also have about 13% who do research and study homeless Veterans; About 15% who are policy makers or administers; 16% work with homeless Veterans in another capacity and about 20% do not work with homeless Veterans. Thank you for those replies.

Dr. Gabrielian: Sounds good. So it sounds like a good portion of the audience has a lot of familiarity with this topic. This is kind of a trick question because I know many people should be answering several of these answer choices instead of just one. So I’ll try to keep that in mind as we move forward. So just a little bit of background information. This may be review for many of you. I think it’s become very clear in the popular press, as well as, for those of us within the VA. The VA has really made a central aim to end Veteran homelessness with really the ambitious goal of ending Veteran homelessness by year 2015. The way that we get our best prevalence estimates today on homelessness are really through these point and time counts for all the individuals who are homeless are counted on single night really to just give us ballpark of how many people are homeless on a given night, as well as, over the course of the year. So our most recent data from these counts come from a single night in 2012 in which 62,619 Veterans were homeless so representing about 13% of all homeless adults. It’s always important to keep in mind, as we look at this point in time estimates, that that’s really a rough estimate of a single and night and that many more Veterans are really homeless over the course of a year. We know that Veterans may be at higher risk for becoming homeless in the civilian population and there’s really a variety of reasons of why this might be the case. There certainly are experiences unique to military trauma such as combat exposure, military sexual trauma that predisposes Veterans to becoming homelessness. Also civilian experiences like childhood adversities are quite important as well. Regardless we know that homeless Veterans are a vulnerable population. I think many of us that do clinical work with this population are intimately aware with the high rates of medical illness both acute medical illness and chronic medical illness that we see in this group combined with psychiatric problems, alcohol, tobacco and other drug use. It really spans from risky use to severe dependence. This is compounded by fragmented health and social service use both within the VA, as well as, within the community-based private—pubic sector and results in a age-adjusted mortality that’s about two to ten times that of their housed peers depending on what study we look at. 

So with that said the unfortunate reality is that there’s a paucity of information about best practices and homeless-focused primary care and that’s really how this study was born. So we can see that the primary care needs of this patient population are complex at their baseline and they’re really compounded by poor social support and competing priorities for things as basic as food, clothing and shelter for this population. There are a few examples in our literature to date before the birth of the Homeless PACT Project about VA-based primary care for homelessness and those are really centered at two sites. So here in Los Angeles there’s been a co-located VA Primary Care Mental Health and Homeless Service Clinic located within our mental health building distinct from where the hospital is on our campus and really tailoring care to a homeless mentally ill population. An important distinction between this clinic and our PACT program is that the services here are co-located but not integrated. Regardless, outcome data from that clinic has shown that patients who receive care in this co-located clinic have higher rates of primary and preventative care than their homeless peers. Dr. Tom O’Toole who’s the National Director of the Homeless Project has published quite a bit about his homeless-focused VA Primary Care Clinic in Providence, Rhode Island. In his clinic he showed greater improvements in chronic disease outcomes compared to historically cohort of homeless Veterans, as well as, patients enrolled in this clinic having fewer non-acute Emergency Department and inpatient admissions for general medical conditions. So some promising outcomes but not really some clear best practices for clinics across the VA to implement to treat homeless patients in primary care settings. 

So the health care for the Homeless Veterans Program that many of us are quite aware of, already offers a host of services for homeless Veterans. What it really lacked was a homeless focused primary care initiative and such was the birth of the Homeless PACT. This really represents a unique collaboration between the office of homeless programs, the office of primary care operations and in 2002 the Homeless PACT’s were launched as a demonstration project at 32 VA facilities across the country. Really adding a new dimension to the HCHV program. 

So the PACT program as most of know are patients centered medical homes and as follows the Homeless-PACT’s are patient centered medical homes for homeless Veterans. The unique feature that really allowed us to build this quality improvement project is that were some salient features that guided HPACT implementation nationwide that were quite general. The PACT’s were charged with tailoring their clinical and social services to homeless Veterans. To actually get patients into the clinic there was a need to establish processes, to identify and refer appropriate Veterans who were homeless and would benefit from these services, as well as, the PACT model to integrate distinct services, mental health primary care integration. We’ve all heard a lot about that within the PACT model. Here, as well as, addiction services, integrating those services into the Homeless PACT's was a key thing that these clinics were charged with. Now with that said new programs must fit local contextual factors and even though there were these guiding implementation features there was no explicit instruction as to how to structure each HPACT so each new program had to fit things as basic as space, personnel, infrastructure, as well as, be reflective of the institutional and community resources that play at each of these VA’s. As a result very different models of homeless-focused of primary care evolved nationwide. We really saw this as an opportunity to say each new HPACT afford the chance to explore how variations in their initial service design actually influences the initial cohorts of patients seen in each clinic and services delivered. So I’ll go into that in a bit more detail.

This is a case study of three newly implemented Homeless PACT’s. We looked at the clinics at Los Angeles, at Birmingham and at Pittsburgh. This is really a convenient sample. It was born out existing collaborations between the authors and really was a reflection of a conversation of how contrasting in the clinic structures were at each of these HPACT’s and also noting the geographic diversity of these three sites. Our goals were really to compare to our clinic structures to compare the demographics, the housing statuses, diagnoses and health service utilization patterns of the initial cohort seen at each site. With the goal not to do a comprehensive program evaluation but really to facilitate iterative of quality improvement and add to the little literature that existed about focused-focused primary care. 

A little bit about our methods. We started with authors at each site trying to describe the clinic structure. So independently developing a list of organizational domains by which to describe each HPACT using those three overarching principles of the HPACT that were provide centrally. The ones I went over just a few slides ago. After looking at the clinic structures we were really very interested of how the structures of each clinic interplay with the patient characteristics. So we looked at the initial patient cohorts—the patients enrolled in the Homeless PACT’s from April 30 to September 30, 2012. Went to our CPRS records and extracted things like demographics, housing status, diagnoses, VA health care utilization. Really looking at the six months before the initial visit to HPACT, which we call the index visit. We also wanted to look a bit longitudinally to see what the impact of enrollment in HPACT was so we looked within six months of the initial visit to the Homeless PACT’s and looked for changes in housing status, as well as, VA health care utilization patterns. I’ll show you a bit about our data. 

Let me see if I can get our arrow to work here. So at Los Angeles the clinic as was born as an evening clinic, co-located with the Emergency Department and the system—if I can move this here—so the Emergency Department nurses would triage Veterans by clinical acuity just as they would in an emergency room at any time of day. However, I’ll walk us through on this right side. When the Homeless PACT was opened the nurse would determine if a Veterans was appropriate for outpatient care and if the clinical acuity was low, so they were appropriate to be seen in an outpatient setting the patient’s received a brief paper-based screening which would identify whether or not they were homeless or at risk for becoming homeless and individuals who screened positive on the screener were offered a visit in the Homeless PACT. Now they could decline the visit and go the emergency room as they would any other time of day or they could accept that visit and be seen in the Homeless PACT and be offered enrollment in that PACT. So a system really based out of the normal emergency room triage process but really offering this other avenue of care for people who could be seen in a primary care setting. You’ll see a bit how that contrasts from these other two clinics. I should say that these are the models that were kind of the initial iteration of each clinic and they’ve really evolved over time. Pittsburgh was unique in that it already and a PACT team that provided addiction-based PACT services. So primary care providers with addiction expertise with buprenorphine certification that had expertise and thought that they were perhaps the best team equipped to take on the roll of the Homeless PACT. So this existing team referred Veterans who were already empanelled on their PACT who they knew were homeless or who were at risk for becoming homeless. Other VA providers could refer Veterans who were homeless or at risk for homeless who did not have a primary care provider. These Veterans didn’t have to have an addictive disorder diagnosed, many of them did that perhaps wasn’t diagnosed but really the team that had these addiction-based services took on this additional role regardless of whether or not the Veterans had an additive disorder. So that contrasted even further from the structure at Birmingham.

So Birmingham’s clinic was actually put within a traditional VA primary care clinic. It was a daytime clinic similar to the Pittsburgh Clinic but it recruited patients in very different ways. The Health Care for Homeless Veterans program at Birmingham would see Veterans for seeking housing, seeking residential rehab, seeking other traditional HCHB services but who weren’t linked up to primary care. Here the HCHB program would actually refer those Veterans to the Homeless PACT as a source or primary care. They also were unique that from the get go, I think some of the other sites have done this since that time, offered street and shelter-based outreach. So had a designated outreach worker who went to emergency shelters in the Birmingham area and recruited homeless Veterans who may have been disengaged with care. The Homeless PACT staff at Birmingham also marketed the clinic to the VA and non-VA services that worked with homeless persons with hopes that would recruit patients who would be appropriate for HPACT here who may be seen other sort of settings primary care otherwise. 

Some additional clinic characteristics that I wanted to note—so all the clinics employed a mix of open access so drop in visits and scheduled appointments with a notion that scheduled appointments were often very, very challenging for this patient population. Across sites primary care providers were really chosen for their expertise in both homeless populations, as well as, illnesses and conditions that are often seen in homeless people such as additive disorders. Wanted to speak a bit to the integration of services. We talked about a bit the integration of mental health and alcohol, tobacco and other drug use services. These strategies for this differed across the sites and again these have changed over time but with the initial versions of the clinics, at Los Angeles there was a mental health clinical nurse specialist on the team who would do some triage and some education and also be able to do some warm hand off to specialty care within the Los Angeles site. At Pittsburgh because the primary care providers were from that addiction PACT and had that expertise and buprenorphine certification there was a lot of embedded substance abuse services but certainly specialty care referrals needed to be as well. At Birmingham there as a psychiatrist actually within the Homeless PACT and that person would also facilitate specialty care referrals as needed and also provided mental health within the clinic itself. 

Moderator:I’m sorry to interrupt you Sonya. For our attendees your line should be muted. So please press mute on your telephone. We don’t want hear what’s going on in your office. Thank you.

Dr. Gabrielian: Thanks Molly. So we’ll go a bit through our results and these are the results of our patient characteristics. You’ll see in our three columns that we have the Los Angeles site, the Pittsburgh site, the Birmingham site. So remember were going from April 30th to September 30, 2012 so we’re talking about small numbers of patients in the 30’s and 40’s of each site. Not surprisingly it’s a predominantly male population. A population in their early 50’s. About 66% of the Birmingham site was African American and 17% of the Los Angeles site was Hispanic but that we think is probably reflective of each of the cities and their composition. 

So the housing status. I want to go over the baseline housing status which we really abstracted from the index visit to the Homeless PACT, as well as, looking at six month follow up.  Look at changes across the three sites. What we saw is we looked at which patients were unsheltered versus what patients were sheltered, as well as, what patients were housed but deemed to be at risk for homelessness. At Los Angeles with the clinic being born in the Emergency Department there was a higher number of unsheltered homeless patients who were seen at first so 26%. Well note that over six months at Los Angeles there was a notable shift with an increased number of sheltered homeless patients, which we would see as a success. So there was a shift from having the most unsheltered homeless and that number going down quite a bit and seeing a rise in the number of sheltered homeless. Pittsburgh’s Clinic was unique in that if we remember that addiction-focused PACT picking patients off their panel who were at risk for homelessness or who had been homeless, a large number of the patients were housed compared to the two sites originally. When those patients lost housing they tended to go into a sheltered situation as opposed to becoming unsheltered, which we would also view as a success. At Birmingham they actually saw real life changes in the number of patients housed, which was quite remarkable. Initially they had the most sheltered homeless and you’ll remember that Birmingham employed the shelter-based outreach and 6% were initially housed and that went up to 17% in six months. So some different changes in the housing pattern seen over six months at each of the three sites. 

We looked at chronic medical conditions that patients suffered from at each site. We looked at mental health and addictive disorder conditions and I’ll just go over a few of these. We selected chronic medical conditions that are typically seen in primary care settings, as well as, typically seen within the homeless population and I think the important take home point from this slide is that were high rates of chronic medical conditions across the board. A few interesting things to note. At Birmingham over 50% were diagnosed with chronic pain. At Pittsburgh over one-third were diagnosed with hepatitis C. We might think about that hepatitis C number in Pittsburgh as being related to that being a clinic that saw a lot of patients with addictive disorders and possibly IV drug use. 

When we looked at mental health and ATOD diagnoses, again, a similar pattern. High relates of mental health problems, high rates of addictive disorders. Close to 50% of patients across all three sites had mood disorders. Los Angeles with its Emergency Department base had about one-fifth of its patients with psychotic disorders, which differed from the other two sites. Birmingham had high rates of alcohol use disorder, about 60%. Pittsburgh, again, the buprenorphine availability saw that 21% of its patients with opioid use disorders. 

Looking at health care utilization patterns, again kind of keep in mind the structure of clinics as we go through each of these. Los Angeles with the clinic being housed in the Emergency Department actually saw an initial increase in Emergency Department use, which probably is not too surprising given the location of the clinic. The success here is really the number of patients who got hooked up with mental heath care, with addictive disorder care and those are some pretty significant gains among this patient population. Now at both Pittsburgh and Birmingham they say the success of seeing a real life decrease in Emergency Department use. At Pittsburgh they also saw an increase in linkages to mental health and probably with more addictive disorder services being embedded in the clinic. There was a decrease in ATOD referrals among those patients. With that in mind I want to make sure that I mention our limitations. This a very small sample size with very limited longitudinal outcome data. We’re really looking at the first six months of care within the Homeless PACT’s and we’re relying VA medical record review. So we’re not able to capture public sector use that’s important in this population and we’re really not able to account for differences in community context—available non-VA resources, the size of the homeless population at each site, which are important but not included in this initial exploration of the data. With that said what we took as the major take home point is that the contrasting organizational structures of each site were reflected in the patient characteristics and the changes in housing and VA health service use that we saw over six months. So for other Homeless PACT’s or for other non-VA sites trying to build primary care medical homes for homeless patients, really what we would kind of take home from this is that it’s important to think about the gaps in care, to think of the population that the clinic aims to serve and to structure that clinic really to reflect that patient population and the aims of each clinic. Los Angeles the co-location with the Emergency Department resulted in the highest rates of unsheltered patients, highest rates of persons with psychotic disorder and high rates of patients who had been frequent utilizes of the Emergency Department. Many of those patients became sheltered and became engaged in substance abuse and mental health care despite the location in the Emergency Department. At Pittsburgh the clinic grew from an addiction-focused team that saw patients with the highest rates of opioid misuse, as well as, hepatitis C, achieved decreases in Emergency Department use and when those patients lost their housing they stayed sheltered. Birmingham really from the get go employed community-based outreach, was able to recruit the highest number of patients from emergency shelters and many of those patients became housed and used the Emergency Department less. So really different structures of each clinic are reflected in some of the initial outcomes that we see. I’d like to give special thanks to the clinicians across the sites, as well as, our facilities and administration at each facility and turn it over to Dr. Dichter. I’ll take questions at the very end.

Moderator:Thank you so much Sonya. Melissa if your line isn’t un-muted just press star zero and ask the operator to moderate it. All the attendee’s lines should be muted so please press mute on your telephone...Okay. I think that Melissa is having her line moderated now so please just hold on for one second. For those of you that joined after the top of the hour if you have a question for either or our presenters simply use that Q&A box located in the upper right hand corner of your screen and we’ll get to the questions at the end as Sonya said. Thank you...Thanks for your patience everybody. Vance is having a lot of technical difficulties today so we’re just waiting for Dr. Dichter to get her line moderated from the operator and it will take just a second here. Melissa once you’re on the call just go head and start speaking. ...In the meantime, Sonya do you have any more comments you’d like to make.

Dr. Gabrielian: Not right now. 

Moderator:Okay thank you.

Dr. Dichter: Can you hear me now?

Moderator:Yep you’re coming through. Thank you.

Dr. Dichter: Like that Sprint commercial. Excellent. Okay. Thank you everyone. Let me advance the slide here. Okay. Excellent. So moving forward before I begin I’m talking today about intimate partner violence, which I’ll refer to as IPV specifically experiences of intimate partner violence or what some people think of as victimization among women VHA patients and women Veterans in particular. Early cyber seminars as part of the spotlight women’s series has also addressed this topic in the VA setting and have presented excellent information about the background on this topic, as well as, what healthcare providers can do. Rather than reiterate that information today I will strongly encourage you to view the archives of these earlier cyber seminars. It seems like this spotlight women’s health series does one of these a year. These have really been excellent. So the link at the bottom of this slide will take you to the cyber seminars catalog where you can view these archives if you haven’t already seen these presentations from my colleagues. 

We’ll start out with a poll question. This question is how knowledgeable do you feel you are about IPV, which again refers to intimate partner violence? Just a broad knowledge question. I will go though the response options. The first is I’m an expert in this area. The second is I have extensive knowledge in this area but I’m not an expert. Third, I have pretty good awareness of the issues. Fourth, I know a little bit about IPV. Fifth, I do not know much about IPV. Sixth, I do not know anything about IPV.

Moderator:Okay. Thank you.  It looks like a good portion of our audience has responded. About a 50% response rate. The answers are still changing but we have some rough estimates. Looks like five people consider themselves experts. Around 21% say they extensive knowledge. Around 32% have a pretty good awareness of the issues. Around 19% know a little bit about intimate partner violence. Around 10% don’t know much and 12.5% say they don’t know anything about it. Thank you for the responses.

Dr. Dichter: Thank you. So we have a pretty good mix here and it’s not surprising to see that many people feel that they don’t know anything about this topic. What I think is important to consider is that IPV affects many infatuations that we see in VHA. Again, I’ll refer you those other cyber seminars and just provide you just some brief background here that IPV or Intimate Partner Violence includes various forms of violence. Physical violence can include, for example, hitting, pushing, punching, stabbing, slapping, and etcetera. Psychological violence refers to behaviors that are threatening, belittling, also yelling, name calling etcetera. Social violence is a term that’s not often used but refers to acts such as isolating the individual, alienating the individual from friends and family, economically restricting the individual would include things like preventing someone from working and earning an income, restricting someone’s access to finances. Sexual violence refers to forced or coherence sexual behavior and that’s in a broad spectrum. It can refer to rape, forced or coerced intercourse, insistence on sex without a condom for example. Stalking or harassment refers to following, spying, sending repeated or unwanted messages, refusing to stay away. IPV can be perpetrated by a current or former romantic or sexual partner. It is often perpetrated by a former romantic or sexual partner, particularly stalking or harassment that may continue after the relationship has ended. We know that more than one in three women in the United States experience physical violence, rape or stalking by an intimate partner in their lifetime and women Veterans are at particular risk. We’ve done research to show that lifetime rates of reported intimate partner violence are higher among women Veterans than non-women Veterans in the community. We also know that IPV is a major source of morbidity and mortality for women associated with a wide variety of acute and chronic mental and physical health problems, social and economical impacts and social health risks. It’s important to note that although the focus of today’s presentation is on women in particular both men and women do experience IPV, although women are more likely to experience IPV and may suffer more extensive, physical, psychological and social impacts from the experience of IPV. 

Today I’m going to talk about the findings from a research study that was funded by our VISN 4 Center for Evaluation of Patient-Aligned Care Teams. In this study our aims were to identify the scope of IPV experiences and associated health care needs among women Veterans who are receiving care at VHA and to identify the opportunities and options for IPV assessment and care in the VHA setting under the PACT model. In this study we had three phases. The first phase we spoke to women Veteran patients about their experiences with violence, experience with talking with health care providers about violence. In phase two we followed up with qualitative in-depth interviews with a portion of the participants from phase one to learn more in the participants own words about the intersection of IPV and military service and health care and health care service needs. In the third phase of the study we conducted telephone qualitative interviews with clinicians across VISN 4. These included primary care providers, gynecologists, women Veterans program mangers, MST coordinators, mental health providers and social workers. 

In terms of our patient population. These patients were recruited from the Women’s Health Clinic at the Philadelphia VA Medical Center. These are the demographics for the survey participants and then those sub-sample of participants who participated in the phase three, I’m sorry, the phase two interviews. So we can see that the age range was 22 to 64 for the full population. We limited our sample to ages 18 to 64 so we excluded anyone older than age 64. Reflective of our patient population in general the majority of patient participants identified as African American. Most had attended at least some college. Most were not employed and the majority said that they either had just enough money to get by or that they couldn’t make ends meet financially. 

In terms of their IPV experiences these were measured with questions from the Conflict Tactic Skills short form. 85.9% of our participants reported that they had experienced any form of IPV in their lifetime and 39.4% reported that they had experienced any form IPV in the past 12 months. You can see the breakdowns and for each type of violence experience. The words in italics represent the actual question items, what they were asking. So for psychological violence for example, we asked participants to identify whether or not their partner had ever insulted, swore, shouted or yelled at them or a second item was destroyed something belonging to me or threatened to hit me. That’s the same for the other two forms of violence. 

Then looking at the timing of IPV exposure relative to military service. We asked them for each of these types of violence, did this happen to you before you entered the military? While you were active duty in the miliary and since leaving the military? The greater proportion of patients reported experience of IPV with each time periods. It’s important to note that the time periods are not equal in length so for example, if someone entered the military at age 18 there may not have been a lot of time before that to have an opportunity to have experienced IPV. Participants served in the military for varying lengths of time from less than one year to more than twenty years. They’d also been out of the military for varying periods of time. These data do show, however, that women Veterans are experiencing IPV after leaving military service. So when we just ask about lifetime experience we don’t know when they’ve experienced that but when we look at these data we can see that women are experiencing IPV at all three time periods and particularly important for the VA is that their experiencing IPV while they’re Veterans, that is after they have left the military. 

The next poll question here focusing on clinicians but if you’ve never worked as a clinician you can still respond to the last item on this poll as I’ve never worked as a clinician. The first item is, yes, I routinely screen patients for experience of IPV. The question is, have you ever asked the patient about experiences with IPV. The second item is, yes I have asked the patients about IPV but do not routinely screen. Third is no I have never asked a patient about IPV. Fourth, again is I have never worked as a clinician. 

Moderator:Thank you. It looks like the answers have stopped streaming in. We have roughly 17% who routinely screen, make that 18%. We have about 37% that have asked patients but don’t routinely do it. About 8% say they have never asked a patient and 38% do not work as clinicians. 

Dr. Dichter: Thank you. Most of the clinicians responding to this poll indicate that they have, at least once, asked a patient about experiences of IPV. 

Moving forward I will report the results of our survey with our 249 women Veteran patients about their experiences of talking to health care providers about IPV. We asked has a health care provider ever asked you about safety, violence or stress in your relationship or with an intimate partner; 55% of our participants said yes a health care provider had ever asked them about this. This is ever in their lifetime. Then we asked what type of health care provider has asked you about this? So 36% said a primary care provider had asked them about this; 14% said a gynecologist had asked them and 30% said a mental health provider had asked them about this. So the participants are reporting that their most likely to be asked in primary care, although, it’s important to note that not all the patients have necessarily received care from a gynecologist or a mental health provider. 

Next we asked have you ever told a health care provider about violence or safety concerns you were having in an intimate relationship; 27% of our participants said yes they had told a provider about this. Now keep in mind that 27% are reporting that they have told a health care provider about this versus more than 85% who reported that they had experienced intimate partner violence. 12% said that they had told their primary care provider. 3% said they told a gynecologist and 21% said that they had told a mental health provider. So they’re most likely to disclose experiences of partner violence to mental health providers.

Third we asked patients do you feel that health care providers should ask about safety, violence, or stress in intimate relationships; 83% of our participants did endorse this time; 6% said no; and the other 11% said that they’re not sure or they don’t know or it depends. Things that it depended on were, for example, reason for visit. If they were there for some reason related at all to the violence. If there were signs of violence or abuse, bruises or unusual behavior. Third, the patient-provider relationship and sensitivity. So it being important for they’re to be a safe environment to have such disclosure. 

Moving onto the findings from our qualitative interviews with patients and providers. The major theme that came out is that both patients and providers noted the importance of asking patients about intimate partner violence. That asking facilitates disclosure and spontaneous disclosure that is not prompted by inquiry is quite rare. So one patient said no one ever asked me about it. You know I was walking around with a black eye and not a single question. So I may have talked about it if I had been given the chance but I wasn’t going to bring it up on my own. Patient and providers also emphasis that it is important to ask more than once. Ask again. The patients may not be ready to disclose the first or even on the second time that they are asked. The box outlined in blue is a quote from a patient who said that she said no when she was first asked because she didn’t want talk about it at that time. When she felt more comfortable with the provider she may feel more comfortable opening up. Then a provider said is what I always feel is that by asking the question each time the patient knows this is a safe environment in which they can discuss these types of things and they may not do it the first five times but they might do it the sixth time. So just asking that question puts it out there and asking multiple times is important to reinforce that this is a safe place to do this and that is something that the providers care about. Making it safe to disclose is important. The decision to disclose may depend on comfort with the providers. The patient said if you feel comfortable with the provider you can disclose. If you don’t feel comfortable with a provider you’re unlikely to do so. Even if a patient doesn’t disclose at that visit just asking about it can be an important intervention. It can show the patient that this is something that you as a provider cares about. The patient may not be willing to disclose on that visit but might consider doing so on a subsequent visit. There are benefits of disclosure in of itself that patients said that even having the opportunity to talk about this can really be helpful. 

Moving forward we also asked the providers about how addressing IPV might work in the VHA PACT model. One issue that came up, of course is, what providers should do when a patient says yes. So it’s important to have the resources in place so that providers can offer support to a patient who does disclose or in cases of suspected IPV. The clinicians noted that those kinds of resources are rarely in place right now in VHA. They don’t know who they can turn to, to get more support for themselves and their patients. 

Next there are some VA-specific considerations that manifest as barriers to addressing IPV in the VA setting. One issue that participants among the providers brought up is that there may be a concern about no being able to see the patient in private. That there are policies permitting family members and others in the exam room, which makes it challenging then to be able to ask these questions in private and address these issues in a private setting. Participants also noted concerns about attributing PTSD or other conditions to non-military related IPV. So this partially came up in terms of Comp and Pen exams that patients may be concerned that if they talk about this they won’t get their service connected disability ratings. The trickiness of utilization of community-based series. So communities in the United States have IPV services that many are very good but the VA providers often feel a barrier to referring to or connecting to these services outside of the VA setting. However, the PACT model does present some opportunities that are unique for addressing IPV. The PACT model supporting the idea of the whole person facilitates addressing topics like IPV. Having a team-based approach can also be helpful with the onset availability of social workers and mental health providers. Participants also noted a potential limitation that there may be concern about confidentiality with spread of information across multiple team members. There’s also some ability to utilize the various team members in different ways. For example an RN that could be doing the initial screening; the social worker could do some more in-depth counseling and assessment and the PACT model focus on integration of care with specialty care community and family. Here we have a representation of the PACT model and the integration of care that emphasizes utilization of all these various resources to support patient health care needs. 

Finally some conclusions. Women Veteran VHA patients experience high rates of IPV before, during and after military service. We know that health care providers can help patients through asking about IPV and connecting patients with services; that the inquiry should be repeated and conducted in a sensitive manner and in a safe setting making it comfortable for the patient to disclose; that coupled with inquiry we need to have resources, protocols and education to support providers and their patients and that the PACT model may be used to facilitate IPV inquiry and support. 

I have here a list of reading and resource and at the bottom the National Domestic Violence Hotline number to provide more information particularly on providing clinical care around IPV for women patients. I’ll put up our contact information that you can have while we go through questions for myself and for Sonya.

Moderator:Great. Thank you to both of you. At this time we’d like to hear from our attendees. So please use that box located in the upper right hand corner, the Q&A box to submit any questions or comments you may have for the presenters. I am not a content expert so please write full sentences and avoid acronyms if at all possible. Throughout the presentation I did see a couple of people raising their hands using the little hand raiser icon. Don’t use that just feel free to write in your question or comment and I’ll read them aloud in the order that they are received. Also if you could specify which presenter your question is for and that will also help us answer them in a timely manner. We don’t have any pending at this time but we’ll give people a little bit more time to get those written in. Here we go. The slide of the constellation of services, circles within circles is very nicely done so thank you very much. Thank you to our attendee. We also do encourage your comments. A couple of people have inquired if this session will be made available later on. Yes we are recording it and we will posting it in our archive catalog. You’ll receive a followup E-mail with that link. So it looks a couple of attendees are wondering how to get the slides. There’s a hyperlink located in the reminder E-mail that you used to enter today’s session and you can just click on that link and get a PDF of the slides. They also will be posted in the archive catalog along with the recording. Looks like we don’t have any other questions pending at this time. Would either of you like to give any concluding comments?

Dr. Gabrielian: Just that I’d be happy to take questions by E-mail if they come up later as well. 

Moderator:Thank you. We appreciate you making yourself available for follow up on this topic. All right we do have a question. Is there a specific tool for screening that you would recommend?

Dr. Dichter: So this is Melissa. I assume that’s for me also. There is a homelessness risk assessment tool that’s currently being used as a clinical reminder in the VA. There isn’t a specific tool yet that’s in place in the VA for across the board for assessing intimate partner violence, however, there is a published tool that has been validated for use in the VA setting with women patients by my colleague Kate Iverson and you can refer to their earlier cyber seminar I noted on that. That tool is called the EHITS, which is the Extend, HITS stands for hurt, insult, threaten, and scream. It’s a screening tool for intimate partner violence and that’s a tool that’s being recommended for use in the VA setting. The original HITS is just those four items. The extended version includes a fifth question about experience of sexual violence. 

Moderator:Thank you. We did also have one of our attendees offer up that. HITS is one that often gets used in research. This is another question for you Melissa. Given the majority of Veterans are male how do we address when a Veterans volunteers that he may have engaged in IPV as a perpetrator? It’s a really excellent question and one that VA researchers and policy makers and clinicians are furiously working to try to address—we don’t have good screening tools for perpetration or use of violence. Note that both women and men can and do sometimes use violence against their intimate partners. Many communities have community-based programs that can address this, although their not as widely spread as victim services of intimate partner violence so I think it’s a question that’s still somewhat unclear, although our VA services, particularly through mental health, PTSD services and family support services are often prepared to address some of the issues that are related to use of violence in relationships. Still this is a very, very underdeveloped area and one that needs a lot more work. 

Moderator:Thank you for that response. As you both mentioned before we do have some achieve sessions and a few of them are on IPV and address that specific question so feel free to view those in our achieve catalog. That is the final question that has come in for our attendees. I will end the meeting in just a moment. There is a survey for you to fill out to get some feedback from you. It’s your opinions that help us—chose which presentations to publish. Also please join us on the 3rd Wednesday, next month, at the time noon eastern for our next PACT presentation in this series. So I’d like to thank our attendees for joining us and I’d like to also thank both Sonya and Melissa for presenting for us. You did a wonderful job. Thank you everybody. Have a nice day.

Dr. Dichter: Thank you.

[End of recording]

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