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Domestic Violence Screening and Documentation DONALD CLARK MD MPH Medical Epidemiologist Albuquerque Area Southwest Tribal Epidemiology Center Rachel Locker MD Warm Springs Health and Wellness Center , Warm Springs OR 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. Domestic Violence: Chronic ―disease‖ with acute exacerbations Injuries Often Seen • Head and neck • ―Swimsuit‖ distribution • Multiple sites • Different stages of healing • Inconsistent w/ reported mechanism of injury • Delayed care Medical Presentations  Higher levels of smoking  Chronic pain syndromes (GI, joint, chest, back, abdomen and pelvis)  ―Noncompliant‖  ―Uncontrolled ____ ―(fill in blank) Psychiatric Presentations • Less favorable impression of physical and mental health status • Nonconsensual sex • Depression Psychiatric Presentations • Generalized anxiety • Depression • PTSD • Substance abuse GYN Manifestations • Sexual dysfunction • Dyspareunia • Recurrent UTI’s • STI’s • Chronic pelvic pain OB Manifestations • Late and intermittent prenatal care • SAB and low birth weight babies • Placental separation • Antepartum hemorrhage • Fetal fracture • Preterm labor Medical Presentations More abuse = more symptoms 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 Kids – The ―Forgotten Victims‖ • ―Intervention‖ injuries • Bystander injuries • Injuries to child to control mother’s behavior or hurt her • Direct and intentional child abuse Kids – The ―Forgotten Victims‖ • Custody disputes • Long-term cognitive, behavioral and psychological effects 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%) 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 Mental illness Battered mother Drug abuse Criminal behavior Childhood Abuse: Psychological Physical Sexual (%) 23.5 18.8 12.5 4.9 3.4 11.0 10.8 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 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 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 Violate or Respect Confidentiality Fail to respond to her disclosure or promote access to community services Ignore the need for safety or Help her plan for future safety 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 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 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 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) 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) 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 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 Comment Present Past Refused Unable to screen Electronic Record • Reminders improve providers memories • Easier documentation – one place only