institutional and statewide policies on ipv screening

Institutional and Statewide Policies on

IPV Screening

Healthcare SummitOctober 24, 2014

Kathy Franchek-Roa MDUniversity of Utah

Kathy.franchek@hsc.utah.edu

Objectives Discuss the association

between childhood adversity and lifelong health

Summarize national recommendations for screening patients for IPV victimization

Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

Summarize national recommendations for screening patients for IPV victimizationUtilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

Adverse Childhood Experiences

Obesity is not the problem–

it is the solution

Vincent J Felitti MD

Felitti 2001

How does this happen, this reverse alchemy, turning the gold of a

newborn into the lead of a depressed, diseased adult?

Multiple

ACE•Child Abuse•Caregiver -IPV -Mental Illness -Substance Abuse -Incarceration

High Risk Health

Behaviors•Smoking•Alcoholism•Illicit Drug Use•Sexual Promiscuity•Unhealthy Diet•Physical Inactivity•Suicidality

1 Heart Disease

2 Cancer

3 CLRD

4 Stroke

6 HIV/AIDS

7 Diabetes

10 Suicide

12 Liver Disease

Felitti 1998

Disease, Disability, and Social Problems

Adoption of Health Risk Behaviors

Social, Emotional, Cognitive Impairment

Disrupted Neurodevelopment

Felitti 2001; www.cdc.gov/ACE

HTNCADDiabetes

Physical InactivityUnhealthy Diet

Chronic Depression

Disrupted Neurodevelopment leading to physical deregulation

Childhood Sexual Abuse

Felitti 2001; www.cdc.gov/ACE

What’s Your ACE Score?

Childhood Adversity Adversity and on-

going toxic stress exposure during childhood is of critical concern because it can negatively affect brain development resulting in permanent changes to brain anatomy and function

McEwen 2007; 2010

Childhood Adversity A child’s response

to stress may have originated as a biologically based adaptation to the child’s abnormal world

Hibel 2011; McEwen 2007; 2010; Stirling 2008; www.developingchild.harvard.edu

Up to 30% of Childrenare exposed to IPV

McDonald 2006; Moore 2007

Child Exposure to IPV“Domestic violence…seems to be the most toxic form of violence for children…

“For many children, the first lessons they learn about violence are not from television or from the streets, but from their parents.”

Groves 2002

“Patients see doctors because of anxiety, while

doctors see patients because of disease. Therein lies the problem between the two.”

Michael Balint

Maine opens first DV shelter“We will not be beaten”Most US States allow wives to bring criminal action against husband for physical abuse

First marital rape law

National Coalition Against Sexual Assault is formed

HHS establishes objectives for violence1994 VAWA

Violence as a Public Health Issue

SG report listing violence as a priorityCDC Violence Epidemiology Branch2020 Healthy People addresses violence

AMA recommends screening women for DV

Violence seen as a public health issueNational Violence Against Women Survey

USPSTF recommendations for screening women for IPV

SG report listing violence as a priorityCDC Violence Epidemiology Branch2000 Healthy People addresses violenceAMA recommends screening women for DV

Violence seen as a public health issueNational Violence Against Women SurveyUSPSTF recommendation for screening women for IPV

Screening Recommendations AMA AAP ACOG USPSTF recommends that

o Clinicians screen women of childbearing age for IPV and provide or refer women who screen positive to intervention services

o This recommendation applies to women who do not have signs or symptoms of abuse

ACOG 2012; AMA 2008; Moyer 2013; Thackeray 2010; USPSTF 2013

Abuse, Neglect and Exploitation

Purpose of Policy Policy on Abuse,

Neglect and Exploitation is to ensure appropriate guidelines for physicians and staff caring for patients they suspect may be victims of abuse, neglect or exploitation

CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence

Types of Abuse Covered in the Policy

Intimate Partner Violence Vulnerable Adult Abuse Trafficking in Persons Child Abuse and Neglect Any patient who presents

with concerns of abuse, neglect and exploitation

Further additions: chapter specific to sexual assault

CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence

Chapter Organization Definitions Public Health Impact Standards Health Consequences Risk Factors/Presenting Signs

and Symptoms Procedure for Identifying

Victims Procedure Once Victim

Identified Resource and Referral

Information Additional Considerations

Intimate Partner Violence

“Are you here today to be treated for injuries caused by

another person?”

“I am concerned that you may not be in a safe relationship. This can

affect your health and the health of your children. Here are some

resources. I strongly urge you to call the crisis hotline number (800-897-LINK) or speak to a

DV advocate. They can help you.”

Document what patient stated in her own words and what resources were given to the patient.Perform a thorough exam, documenting/photographing injuries

Contact DCFS 855-323-3237 if acts of DV were committed in the presence of a child.

Physical findingsconsistent withassault/abuse?

“I am glad youare in a saferelationship.

Would you likesome

resources in case you or

someone youknow ever

needs help?”

NO YES

Physical findingsconsistent withassault/abuse? NO

Call Law Enforcement

Recommend contactingDV AdvocateSocial Worker/Crisis Worker

YESYES

I ask all my patients if they are in a relationship or in a home with someone who may be hurting or controlling them because this can affect people’s health (and the health of their children).

In addition, you should know that in some instances what you tell me may need to be reported. Are you in a relationship with someone who physically hurts, threatens or emotionally abuses you?

Vulnerable Adult Abuse

Vulnerable Adult Abuse Algorithm Presentation Concerning for Vulnerable Adult Abuse

If you suspect Elder/Disabled Adult Abuse and patient has no

cognitive dysfunction*separate patient from

accompanying adults and ask:

YES Is patient medically stable? NOStabilize patient as

appropriate--then proceed with

algorithm

“Are you here today to be treated for injuries caused by

another person?”

1) Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?2) Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides, other assisted devices or medical care, or from being with people you wanted to be with?3) Have you been upset because someone talked to you in a way that made you feel shamed or threatened?4) Has anyone tried to force you to sign papers or to use your money against your will?5) Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

If YES to question 2,3,4,OR 5

If NO to questions

2,3,4,AND 5

Physical findings consistent with assault/abuse

AND/OR HCP notices: poor eye contact, withdrawn nature,

malnourishment, hygiene issues, inappropriate clothing, or medication compliance issues and elder/disabled adult abuse suspected

Document What patient stated in her/hisown words;

What resources were given to the patient; and

Reports made to authorities

Refer to Social Worker as needed

Reiterate to patient that your hospital is a resource if needed

Ensure follow-up with PCP Consider referral to Geriatrician

CALL LAW ENFORCEMENT ORAPS 800-371-7897

*If patient has cognitive dysfunction consult:PsychiatryNeurologyConsider Geriatrician

CALL LAW ENFORCEMENT ORAPS 800-371-7897

Trafficking In Persons

Trafficking in Persons (TIP) Algorithm Presentation Concerning for Human Trafficking

Is patient medically stable? NO Stabilize patient as appropriate--

then proceed with algorithm

YES< 18 years of age > 18 years of age

CONSIDER OTHER RESOURCES:Notify hospital security if needed Call Social Worker or Crisis Worker if availableUtah Human Trafficking Task Force 801-200-3443Trafficking Hotline for additional info 888-373-7888SANE Nurse Sexual Assault Crisis Hotline 888-421-1100

If you suspect TIP ask:

If you suspect TIP ask questions alone with the patient: “Have you ever been forced to do work when you didn’t want to do?”“Does anyone hold your identity

documents?”“Has your employer threatened you if you

leave?”“Have you ever exchanged sex for food,

shelter, drugs, or money?”

“Are you here today to be treated for injuries caused by another

person?”

Assessment of Potential DangerAsk Hotline (888-373-7888) to assist in assessing level of danger. Be vigilant of immediate environmentQuestions to consider: Is the trafficker present? What will happen if the patient does not return to the trafficker? Does the patient believe he/she or a family member is in danger? Is the patient a minor?

Document what patient stated in her/his own words and what resources were given to the patient.

Important Dynamics for Assessment Keep in mind that the victim may not self-identify as a human trafficking victim Victims have been conditioned not to trust others Victims have been conditioned not to tell the truth Speak to the patient alone without accompanying

adults (adults may portray themselves as relatives) Prioritize the patient’s medical needs and safety as

the primary reason for the assessment

Refer to Social Worker as needed Reiterate to patient that your hospital is a resource if needed Give the patient the Human

Trafficking Hotline Number if safe to do so (888-373-7888; 801-200-3443)

CALL LAW ENFORCEMENT ANDCALL DCFS (IF < 18 YO) 855-323-3237

Child Abuse and Neglect

Child Abuse and Neglect Algorithm Presentation Concerning for Child Abuse/Neglect

YES NOIs patient medically stable?Stabilize patient as

appropriate--then proceed with

algorithm

Physical Injuries NeglectWitness to IPVSexual AbuseEmotional Abuse

Assess for Risk Factors Ask about IPV in the home

Carefully document history using quotes when possiblePerform a careful, thorough physical exam Use body maps and photography to document visible injuriesLabs and Imaging as indicated

CONSIDER OTHER RESOURCESAbuse PediatricianLaw EnforcementChildren’s Justice Center

Assess for Risk Factors See IPV Algorithm

Carefully document history using quotes when possible

Perform a careful, thorough physical exam

For children <14 years: call child abuse pediatrician on call

For children >14 years: call SANE nurse

Contact Social Worker: If available

Carefully document history using quotes when possible

Perform a careful, thorough physical exam

CONSIDER OTHER RESOURCESContact Crisis Worker/Social Worker to help families with homelessness, socio-economic factors, educational needs,drug use, food insecurity and health insurance needsChild Abuse Pediatricianto help with evaluation if neededChildren’s Justice CenterHospital Security Law Enforcement

CONSIDER OTHER RESOURCESHospital Security Call DV Advocate if parent so desires DV Crisis Hotline: 800-897-5465

CALL DCFS 855-323-3237

CONSIDER OTHER RESOURCESAbuse PediatricianLaw EnforcementChildren’s Justice Center

Reminders Activate your

policyo Make it a useful

documento Make it relevant

If you don’t ask—they

won’t tell health care setting

Trauma-informed Care Realization that many

patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma

Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization

“What is wrong with you?”“What has happened to you?”

http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf

Trauma-informed Care Realization that many

patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma

Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization

“What is wrong with you?” “What has happened to

you?”

http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf

Trauma-informed Care What happened is not

nearly as important as what the trauma means to the individual

Screening to identify patients who have histories of trauma and experience trauma-related symptoms is a

prevention strategy With a history of trauma

so common it has been suggested that we should use ‘universal precautions’ when interacting with patients

SAMHSA TIP Series 57, 2014; Harris 2001

10 Principles of TICRecognize the impact of violence and victimization on

development and coping strategiesIdentify recovery from trauma as the primary goalEmploy an empowerment modelStrive to maximize a patient’s choices and control over

her recoveryAre based in a relational collaborationCreate an atmosphere that is respectful of survivors’

need for safety, respect, and acceptanceEmphasize patient’s strengths, highlighting adaptations

over symptoms and resilience over pathologyGoal is to minimize the possibilities of retraumatization Strive to be culturally competent Solicit consumer input and involve patients in designing

and evaluating servicesElliott 2005

Trauma-informed care embraces a perspective that highlights

adaptation over symptoms and resilience over pathology.

Elliott et al. 2005

In Conclusion

Discuss the association between childhood adversity and lifelong healtho “…the need is clear, the opportunities are major…what happens in

childhood…commonly lasts throughout life…Time does not heal, time conceals… The impact of a successful approach here might be as great as that of a major vaccine.” Felitti 2009

Summarize the national recommendations for screening patients for IPV victimizationo “I will remember that there is an art to medicine as well as a science,

and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” Louis Lasagna MD

Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare settingo “I wonder how different my life would have been if someone in a

white lab jacket had sat down, listened to my story, and seen the health issues lurking in my tomorrows.” Survivor

Thank You!

American College of Obstetricians and Gynecologists. Committee Opinion. Intimate Partner Violence. February 2012, Number 518. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-onHealth-Care-for-Underserved-Women/Intimate-Partner-Violence

American Medical Association. Opinion 2.02 – Physicians’ Obligations in Preventing, Identifying, and Treating Violence and Abuse. Available http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion202.page

Balint M. The Doctor, His Patient and the Illness. 2nd Ed. The Bath Press Avon. 1964.

Centers for Disease Control and Prevention. Intimate Partner Violence Consequences. Available http://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html

References

CHIIP—Connecticut Health Initiative for Identification and Prevention. Model—Domestic Violence Hospital Policy. Available http://www.vdh.virginia.gov/ofhs/prevention/dsvp/projectradarva/documents/older/pdf/CHIIP_PROGRAM_Domestic_Violence_Hospital_Policy.pdf

Dahlberg LL, Mercy JA. History of violence as a public health issue. AMA Virtual Mentor, February 2009. Volume 11, No. 2: 167-172. Available on-line at http://virtualmentor.ama-assn.org/2009/02/mhst1-0902.html. 1976

Delphi Instrument. Available http://archive.ahrq.gov/research/domesticviol/dvtool.pdf

Elliott, DE et al. Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology. 2005:33;461–477

References

Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Family Violence Prevention Fund, 1999. Updated 2004. San Francisco, CA. Available at http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf

Felitti VJ et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults—the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245-258

Felitti VJ. Reverse alchemy in childhood: Turning gold into lead. Health Alert. Vol 8 No 1. 2001

Felitti VJ. Commentary—Adverse Childhood Experiences and adult health. Acad Ped. 2009;9:131-132

Groves BM. Children Who See Too Much: Lessons from the Child. Boston, MA: Beacon Press; 2002

References

Harris M, Fallot RD (Eds.) Using trauma theory to design service systems. New Directions for Mental Health Services, 89. San Francisco, CA, 2001

Hibel LC, et al. Maternal sensitivity buffers the adrenocortical implications of intimate partner violence exposure during early childhood. Develop Psychopath. 2011;23:689-701

McDonald R, et al. Estimating the number of American children living in partner-violent families. J Fam Psych. 2006;20:137-142

McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007;87:873–904.

McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health and disease. Ann NY Acad Sci 2010;1186:190-222.

References

Moore CG et al. The prevalence of violent disagreements in US families: Effects of residence, race/ethnicity, and parental stress. Pediatrics. 2007:119(S1), S68-S76

Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;158:478-486

Shonkoff JP et al. Technical Report—The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012:129:e232-e246

Stirling J et al. Understanding the behavioral and emotional consequences of child abuse. Pediatrics. 2008;122:667-673

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014

References

Thackeray JD et al. Intimate partner violence: The role of the pediatrician. Pediatrics 2010;125:1094-1100

U.S. Preventive Services Task Force Recommendations on Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Available http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatmentFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults screening

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