DONALD CLARK MD MPH

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Domestic Violence
Screening and Documentation
DONALD CLARK MD MPH Medical Epidemiologist Albuque
rque Area Southwest Tribal Epidemiology
Center Rachel Locker MD Warm Springs Health and
Wellness Center , Warm Springs OR
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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.

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Domestic Violence

• Chronic disease with acute exacerbations

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Injuries Often Seen

• Head and neck
• Swimsuit distribution
• Multiple sites
• Different stages of healing
• Inconsistent w/ reported mechanism of injury
• Delayed care

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Medical Presentations

• Higher levels of smoking
• Chronic pain syndromes (GI, joint, chest, back,
  abdomen and pelvis)
• Noncompliant
• Uncontrolled ____ (fill in blank)

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Psychiatric Presentations

• Less favorable impression of physical and mental
  health status
• Nonconsensual sex
• Depression

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Psychiatric Presentations

• Generalized anxiety
• Depression
• PTSD
• Substance abuse

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GYN Manifestations

• Sexual dysfunction
• Dyspareunia
• Recurrent UTIs
• STIs
• Chronic pelvic pain

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OB Manifestations

• Late and intermittent prenatal care
• SAB and low birth weight babies
• Placental separation
• Antepartum hemorrhage
• Fetal fracture
• Preterm labor

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Medical Presentations

• More abuse more symptoms

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Homicide

• Female homicides in NM
• 4.9 per 100,000 Native American women
• 1.8 non-Hispanic white women
• 1.7 for Hispanic women

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Female Homicides in NM

• DV was the cause in 46 of Native American Female
  Homicides

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Oregon Statistics

• 1997-2001 Review of Intimate Partner homicides
• 151 women murdered
• 50 (n75) murdered by intimate partner
• 387 men murdered
• 4 (n17) murdered by and intimate partner
• 29 (n5 )of those killed in self defense

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Kids The Forgotten Victims

• Intervention injuries
• Bystander injuries
• Injuries to child to control mothers behavior or
  hurt her
• Direct and intentional child abuse

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Kids The Forgotten Victims

• Custody disputes
• Long-term cognitive, behavioral and psychological
  effects

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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
• (n9,508 adults response rate70.5)

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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

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Prevalence of ACEs

• Household exposures ()
• Alcohol abuse 23.5
• Mental illness 18.8
• Battered mother 12.5
• Drug abuse 4.9
• Criminal behavior 3.4
• Childhood Abuse
• Psychological 11.0
• Physical 10.8
• Sexual 22.0

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ACEs have a graded relationship with

• Ischemic heart disease
• Cancer
• Chronic lung disease
• Skeletal fractures
• Liver disease

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Childhood Exposure to Domestic Violence

• ? ACEs
• Positive, graded risk for
• - Illicit drug use
• - IV drug use
• - Depression
• More Exposure More Problems

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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

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Persons with 4 ACEs had 4-12X ? risk for

• Alcoholism
• Drug abuse
• Depression
• Suicide attempts

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Guiding Principles

• Become advocates for victims and their children
• Change the health care system to better respond
  to domestic violence

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Effective Response Changes In

• Screening for DV
• Assessment
• Intervention
• Documentation

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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!

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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

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GPRA

• Government Performance and Results Act federal
  law
• Performance-based budgeting
• Measurable performance indicators to demonstrate
  effectiveness in meeting Agency mission

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GPRA

• Government Performance and Results Act federal
  law captures
• Screening intentional attempts
• Diagnoses
• Patient education codes

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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

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Barriers To Screening

• Personal Experience
• Brings up memories
• Staff may not be ready to deal with past or
  present personal experiences
• Misconceptions and misinformation

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Barriers

• I Cant fix it
• In medicine we are used to providing a test, a
  pill or something to resolve the problem
• DV is not so easy

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Barriers

• Open Pandoras box
• Fear that not enough time is allowed if this
  patient opens up
• I dont know what to do if she says yes
• Confusion about mandatory reporting
• Competing public health agenda

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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

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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

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Power and Control vs. Advocacy
Violate or Respect Confidentiality
Fail to respond to her disclosure or promote
access to community services
Trivialize the abuse or Believe and validate her
experiences
Advocacy
Blame the victim or Acknowledge injustice
Ignore the need for safety or Help her plan for
future safety
Try to force your choices or Respect her autonomy
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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

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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

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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)

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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 IndiansChoctaw
  Health Center (Choctaw, MS)

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Participating Sites added Phase 2

• Cherokee Indian Hospital (Cherokee, NC)
• Chinle Comprehensive Healthcare Facility (Chinle,
  AZ)
• Crow/Northern Cheyenne Hospital (Crow Agency, MT)
• Kaw NationKanza 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)

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Domestic ViolenceGPRA 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 _at_ 06 rate of 28
• IHS 2010 goal for DV Screening
• 40 for female patients ages 15-40

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GPRA IPV/DV Measure Results

• National Average GY2004
• 4
• National Average GY2005
• 13
• National Average GY2006
• 28

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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

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Documentation in RPMS

• Conducted as and Exam
• Documented as
• Normal/negative- denies past or present DV
• Present acknowledge in the past 12 mo
• Past- gt 12 months ago
• Refused declined exam
• Unable to screen
• Entered as Exam code 34

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Provider Documentation (contd)

• Results can also be recorded by using a stamp on
  the PCC form, or
• Customized PCC template
• Sample PCC text box below

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Electronic Record

• Reminders improve providers memories
• Easier documentation one place only

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