L. Kevin Hamberger, Ph.D. Department of Family and ...Required cme for licensure ... Hamberger, LK,...

L. Kevin Hamberger, Ph.D. Department of Family and Community Medicine

Medical College of Wisconsin

Injuries Mental and physical health and well-being Health Care Utilization

As a Mental Health problem Depression, Anxiety Alcohol/drug abuse

As a Relationship problem Sexual dysfunction Partner as identified patient

As a Child-Related problem Suspected child abuse Child behavior problem

As multiple, stress-related physical complaints

As a “compliance” problem Medication Obstetrics Follow-up for specialty care

Compared to no IPV, healthcare utilization by victims was higher across all categories

As time from the last assault increased, utilization rates decreased

5 years after the final assault, victims’ utilization 20% higher than non-victims

Rivera, et al. (2007)

Children of battered women experience more healthcare utilization and costs than children of non-battered women Mental health services Primary care visits Specialty care Pharmacy services Emergency services (for children directly exposed)

Rivera et al. (2008)

KC 50 y/o African American woman, self-employed

Presentation to FP: “I’m having problems sleeping, feeling stressed all the time, and depressed.”

Sleep onset and interruption insomnia Headaches Nightmares Crying spells Worry Difficulty concentrating and inability to do her job Decreased appetite

She did not mention the assault to her PMD Family gathering

Punched and strangled by husband

Feared for her life

Intrusive thoughts Avoidance of certain situations

B.H. 55 y/o African American woman Married 30 years; 4 adult children Homemaker and part time work with her church

Frequent clinic visitor High blood pressure and headaches Depression

Sadness Guilt feelings Sleep interruption insomnia Overeating and weight gain Low energy and decreased motivation Feelings of hopelessness

Not suicidal Low self-esteem Frequent crying spells

PMD uncovered abuse via case finding

C.O. 28 y/o White female Currently unemployed History of bi-polar disorder and alcohol abuse

Complaints of low back pain

No pathophysiology identified following comprehensive testing and diagnostic studies abuse was discovered via case finding

P.T. 58 Y/O White female Married 33 years Recent empty nest Recent part time employment after years of

homemaking Presented to PMD with anxiety that was not

responsive to medications

Uncontrollable worry and apprehension that “something bad” was going to happen

Increased muscle tension Fatigue Restlessness Increased absenteeism from work

IPV unveiled through case finding

Ongoing debate Studies have not uniformly shown screening to result in

decreased violence or improved health MacMillan et al. (2009), Klevens et al. (2012)

IPV screening and counseling one of 8 prevention services to be offered to women with no cost sharing

US Preventive Services Task Force gives IPV screening in primary care settings a B recommendation – IPV screening has moderate net benefit Service is recommended and should be offered Adequate screening instruments Adequate evidence of effective interventions Risk of harms from screening no greater than small

HITS – Hurt, Insult, Threaten, Scream (Sherin et al., 1998)

OVAT-- Ongoing Violence Assessment Tool (Ernst et al., 2004)

STaT -- Slapped, Threatened, Throw (Paranjape et al., 2006)

HARK– Humiliation, Afraid, Rape, Kick (Sohal et al., 2007)

WAST -- Woman Abuse Screening Tool (Brown et al., 2000)

PVS – Partner Violence Screen (Feldhaus et al., 1997)

Resulted in large-scale screening

Been sustainable

External attempts to induce change have not been effective Professional association position statements Accreditation efforts Required cme for licensure

Reliance on community resources to support change

has been successful…… But there not enough resources And when the funding goes…….

Knowledge

Self efficacy

Clinical skill Hamberger et al. (2004)

Systematic reviews Waalen et al., (2000) O’Campo et al., (2011)

Empirical studies

Minsky-Kelly et al. (2005) Hamberger et al. (2010) Sims et al. (2011)

•Privacy concerns •Time constraints

•Patient f low •Professional/Personal discomfort with subject

System-level interventions at the departmental level

Increase privacy Modify patient flow Provide department-level CQI feedback Stress/vicarious trauma management Ongoing in-service skills training review

L. Kevin Hamberger, Ph.D. Bruce Ambuel, Ph.D. Mary Beth Phelan, M.D. Marlene Melzer-Lange, M.D. Marie Wolff, Ph.D. Amy Kistner, M.S. Clare Guse, M.S.

1) Health Care Advocates—Selected staff receive intensive training in IPV & health

2) Collaboration w/ advocacy agencies & experts 3) Saturation training of all staff 4) Policies & procedures 5) Continuous Quality Improvement 6) Primary prevention

Integration of facts into the healthcare picture Why is this a healthcare problem? Why is this information relevant to HCPs? Why should HCPs make IPV part of their practice?

What skills are involved to effectively work with IPV survivors?

Assure confidentiality Provide emotional support Provide community resource information Danger assessment Safety planning Offer follow-up Documentation

A couple came in to the clinic – each with their own appointment

A couple came in to the clinic – each with their own appointment

The male checks in for both self and partner

A couple came in to the clinic – each with their own appointment

The male checks in for both self and partner Another receptionist observes suspicious behavior

He was talking for his partner Woman partner looked subservient He was rude and aggressive with reception staff

A couple came in to the clinic – each with their own appointment

The male checks in for both self and partner Another receptionist observes suspicious behavior

He was talking for his partner Woman partner looked subservient He was rude and aggressive with reception staff

Receptionist observed bruises on the female patient

Receptionist surreptitiously called the MOA Described the male patient’s behavior Described bruises noted Expressed concern about abuse

Receptionist surreptitiously called the MOA Described the male patient’s behavior Described bruises noted Expressed concern about abuse

MOA decides to call the female patient separately from the male to room separately (invoked clinic policy)

Female patient was roomed MOA notified MD of the situation and separate

rooming strategy and MD agreed MD begins to see female patient with aid of interpreter MOA rooms male patient in a NON-Adjacent room

28 y/o AAF attends clinic for CPE Reports upon screening that she is in a violent

relationship

Partner has threatened to kill her Partner followed her into local police station

where she attempted to make a report She was referred to family court for TRO Partner accompanied her to family court offices

and threatened to kill her if she followed through with TRO

She desisted and returned home Partner took her rent money

Physician asked if she wanted to speak to the Health Advocate

Health Advocate invited to exam room Conducted violence assessment Conducted safety planning Provided resource information Scheduled follow-up contacts

Patient asked for help accessing shelter Advocate contacted shelter

No room No alternatives provided Advocate located area shelter alternatives

Shelter director later contacted for problem solving

Education

Education Discipline and job-specific roles

Education Discipline and job-specific roles Clinic policies and procedures

IPV screening Patients seen alone for part of medical encounter Collaboration with community agencies

Strategies to Measure Effectiveness of Healthcare-Based Domestic

Violence Screening and Intervention

May not be under the control of either the patient/survivor or the healthcare provider Hamberger, Rhodes, & Brown (2014)

Practitioner

Health system

Patient

Clinicians reported significant increases in:

1) Self-efficacy

2) Understanding of referral resources

3) Understanding of legal requirement

4) Clinic’s capacity to facilitate IPV intervention

5) Staff well prepared

6) Increased screening

Compared to “usual care” control clinics, intervention clinics showed: Implementation of new policies and procedures for IPV

screening and intervention Increased locations and numbers of patient education

materials on IPV Increased screening documentation

Changes continued at 2-year follow-up, suggesting

sustained change

SIGNIFICANT FINDINGS favoring intervention clinics IPV screening by doctor or nurse Disclose IPV to doctor or nurse Discuss IPV with someone at a clinic or hospital

Fewer symptoms of injury Drop in clinic visits over time

Randomized controlled trial – 48 total clinics Similar components to Healthcare Can Change From

Within Practice-based training sessions Embedded domestic violence advocate Prompt to ask about abuse

Results Intervention practices recorded significantly more

IPV referrals to advocacy Disclosures of IPV from patients

Intervention is cost-effective Devine et al., 2012

IPV is a public health problem with a tremendous morbidity burden for individual survivors and for society

Efforts to address IPV as a health problem are evolving and showing promise

Systems change that involves a multi-disciplinary approach appears to be the most promising approach to increasing office-based IPV screening and brief intervention

More research using RCTs are needed to validate the impact of healthcare-based screening and brief interventions to prevent and end IPV

Methodological improvements are needed

Ambuel, B., Hamberger, LK, Guse, C, Melzer-Lange, M., Phelan, MB, & Kistner, A. (2013). Healthcare can change from within: Sustained improvement in the healthcare response to intimate partner violence. Journal of Family Violence, 28, 833-847.

Black, MC. (2011). Intimate partner violence and adverse health consequences. American Journal of Lifestyle Medicine, 5, 428-439.

Bonomi, AE, Thompson, RS, Anderson, M, Reid, RJ, Carrell, D., Dimer, JA, & Rivera, FP. (2006). Intimate partner violence and women’s physical, mental, and social functioning. American Journal of Preventive Medicine, 30, 458-466.

Brown, JB, Lent, B, & Sas, G. (2000). Application of the Woman Abuse Screening Tool (WAST) and WAST-Short in the family practice setting. Journal of Family Practice, 49, 896-903.

Devine, A, Spencer, A, Eldredge, S., Norman, R., & Feder, G. (2012). Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programe for primary care: a modelling study based on a randomised control trial. BMJ Open, 2:e001008. doi:10.1136/bmjopen-2012-0011008.

Ernst, A., Weiss, SJ, Chan, E, Hall, L, Nick, TG. (2004). Detecting ongoing intimate partner violence in the emergency department using a simple 4-question screen: The OVAT. Violence & Victims, 19, 375-384.

Feder, G, Davies, RA, Baird, K, Dunne, D, Eldridge, S, et al. (2011). Identification and referral to improve safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: A cluster randomised controlled trial. The Lancet, 378, 1788-1795.

Feldhaus, KM, Koziol-McLain, J, Amsbury, HL, et al.. (1997). Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA, 277, 1357-1361.

Hamberger, LK, Ambuel, B, Guse, CE, Phelan, MB, Melzer-Lange, M, & Kistner, A. (2014). Effects of a systems change model to respond to patients experiencing partner violence in primary care settings. Journal of Family Violence, 29, 581-594.

Hamberger, LK, Guse, CE, Boerger, J, Minsky, D, Pape, D, & Folsom, C. (2004). Evaluation of a health care provider training program to identify and help partner violence victims. Journal of Family Violence, 19, 1-11.

Hamberger, LK, Guse, CE, Patel, D, & Griffin, E. (2010). Increasing physician inquiry for intimate partner violence in a family medicine setting: Placing a screening prompt on the patient record. Journal of Aggression, Maltreatment and Trauma, 19, 839-852.

Hamberger, L.K., Rhodes, K, & Brown, J. (2015). Screening and intervention for intimate partner violence in healthcare settings: The challenge of cr3ating sustainable system-level programs. Journal of Women’s Health, 24, 86-91.

Klevens, J, Kee, R, Trick, W, Garcia, D, Angulo, F, Jones, R, & Sadowski, LS. (2012). Effect of screening for partner violence on women’s quality of life: A randomized controlled trial. JAMA, 308, 681-689.

MacMillan, HL, Wathen, CN, Jamieson, E, Boyle, MH, Shannon, HS, et al. (2009). Screening for intimate partner violence in health care settings: A randomized trial. JAMA, 302, 493-501.

Minsky-Kelly, D, Hamberger, LK, Pape, DA, & Wolff, M. (2005). We’ve had the training, now what? Qualitative analysis of barriers to domestic violence screening and referral in a health care setting. Journal of Interpersonal Violence, 20, 1288-1309.

O’Campo, P, Kirst, M, Tsamis, C, Chambers, C, & Ahmad, F. (2010). Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review. Social Science and Medicine, 72, 855-866.

Paranjape, A, Rassk, K, & Liebschuz, J. (2006). Utility of STaT for the identification of recent intimate partner violence. Journal of the Naitonal Medical Association, 98, 1663-1669.

Rivera, FP, Anderson, ML, Fishman, P, Bonomi, AE, Reid, RJ, Carrell, D, & Thompson, RS. (2007). Healthcare utilization and costs for women with a history of intimate partner violence. American Journal of Preventive Medicine, 32, 89-96.

Rivera, FP, Anderson, <L, Fishman, P, Bonomi, AE, Reid, RJ, Carrell, D, & Thompson, RS. (2007). Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics, 120, 1270-1277.

Sherin, KM, Sinacore, JM, LI, XQ, Zitter, RE, & Shakil, A. (1998). HITS: A short domestic violence screening tool for use in a family practice setting. Family Medicine, 30, 508-512.

Sims, C, Sabra, D, Bergey, MR, Grill, E, Sarani, B., et al. (2011). Detecting intimate partner violence: More than trauma team education is needed. Journal of the American zCollege of Surgeons, 212, 867-872.

Sohal, H, Eldredge, S, & Feder, G. (2007). The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: A diagnostic accuracy study in general practice. BMC Family Practice, published online August 29, 2007. doi: 10.1186/1471-2296-8-49.

U.S. Preventive Services Task Force. (July, 2015). Final udate summary: Intimate partner voilence and abuse of elderly and vulnerable adults: Screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Accessed 12-22-2015.

L. Kevin Hamberger, Ph.D. E-mail: kevinh@mcw.edu Phone: (414) 527-8458