1 Transforming the Health Care Response to Family ViolenceLiza Eshilian-Oates, MD Physician Leader, Family Violence Prevention Program Southern California Kaiser Permanente May 9, 2017 | KP Resident Elective Health Policy Program Family Violence Prevention Program January 28, 2011

2 Transforming the Health Care Response to Family Violence

3 Intimate Partner ViolenceA pattern of coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive social isolation and intimidation Perpetrated by someone who is or was involved in an intimate/romantic relationship with the victim Age: 18-64 Occurs in heterosexual and same sex relationships 15% of the victims are male

4 Making the Case: Why is IPV an important health care issue?IPV is extremely common The health effects are devastating The health care costs are substantial IPV impacts future generations Health care interventions make a difference Set of 9 slides used for Making the Case for the importance of recognizing and interventions for IPV in the health care setting. 4 4

5 MAKING THE CASE Comparison to Other Important Life-Threatening Conditions that Affect Women In the US, each year New cases of breast cancer[1] 211,000  Number of women dying from cardiovascular disease[2] 484,000  Women who are injured from IPV[3] 2,000,000 B: need content 1 in 4 women lifetime prevalence . Breast Cancer Facts & Figures. American Cancer Society: Atlanta, GA Heart Disease and Stroke Statistics. American Heart Association: 2006. Extent, Nature, and Consequences of Intimate Partner Violence. U.S. Department of Justice: Washington, DC. NCJ , 2000. Family Violence Prevention Program January 28, 2011 5

6 IPV Associated with Many Health ConditionsMost common cause of injury in women (18-44 yo) Chronic Disorders Reproductive Health Mental Health Somatic Conditions Asthma Obesity Diabetes Arthritis Cardiovascular Disorders Stroke Cancer Pelvic Pain STI, HIV Cancer Unintended Pregnancy Poor Pregnancy Outcomes (LBW, PTB) Headache Fibromyalgia GI Disorders (IBS, ulcers) Fatigue Insomnia Chronic Pain Depression Anxiety PTSD Eating Disorders Substance Misuse Suicide B: need content Family Violence Prevention Program January 28, 2011

7 Costly and inappropriate tests Increased utilizationFailure to recognize and address IPV results in inefficient and ineffective care Incorrect diagnosis Costly and inappropriate tests Treatment failure “Non-adherence” Ongoing morbidity Increased utilization Lyn: draft comments. This slide also show why I felt it was important to bring to my fellow Chiefs in Scal. Lyn, If you want an example – here are 2: If your partner threatens or hurts you if use birth control, or throws your pills away- this can look to the doctor like a non adherent patient. If the doctor doesn’t ask about the IPV and learn that pills aren’t going to work in that setting, the result may be an unwanted pregnancy w/ the concomitant increased utilization. Unrecognized IPV can underlie the presentation of persistent pelvic pain which then gets worked up with ultrasound/CT/MRI/ procedures when it may be due to physical abuse and marital rape. Cycling thru SSRI’s (and the expense) for depression that don’t seem to be working, may represent unrecognized DV that is impeding improvement in depressive sx. Family Violence Prevention Program January 26, 2011

8 Annual Additional Health Care Costs due to IPV Impact of IPV on KP Region Women Members 18-65 Current IPV+ Annual Additional Cost Colorado: 218,206 8,728 $ 62.4 Million Georgia: 93,506 3,740 $ 26.7 Million Hawaii: 82,147 2,286 $ 23.5 Million Mid-Atlantic States: 218,917 8,757 $ 62.6 Million Northwest: 181,822 7,273 $ 52.0 Million Washington: 214,179 8,567 $ 61.3 Million Northern California: 1,313,533 52,541 $ Million Southern California: 1,402,895 56,116 $ Million Total 3,725,205 149,008 $ Billion B: need content Source: share.kp.org for Membership #’s, Women members estimated based on NCal ratio from quality data. Current IPV estimated at 4%, Hx of IPV estimated at 30% Healthcare utilization and costs for women with a history of intimate partner violence. Rivara, F.P., et al. Am J Prev Med, (2): B_ Mention GHRI has contributed vital research information.- at least 20 publications. We have included some highlights in background materials. Annual Additional Health Care Costs due to IPV $28.6 Million /100,000 women enrollees (age 18-65)* $1,065,000,000 every year for KP (all regions) *Source: Rivara, FP (2007) AJPM, updated to reflect 2014 Dollars

9 IPV Impacts Future GenerationsChildren who witness DV May also be victims of abuse One of the Adverse Childhood Experiences (ACEs) Higher rates of Depression, anxiety Substance abuse Failure in school Becoming victim or perpetrator B: need content domestic violence happens at home. help happens here. 9

10 Most women end violent relationshipsIt takes time: on average 3-5 attempts and about 7 years The majority of women do not have recurrent abusive relationships Clinical intervention helps

11 Healthcare providers can start the processTalking to a health care provider increases the likelihood of receiving DV services Receiving DV services increases likelihood of exiting an abusive relationship Exiting abusive relationship is associated with improved physical health One survivor says “I didn’t leave my husband that day but the physician’s words were part of what it took for me to finally leave. My health is completely back to normal now.” A study of 132 women outpatients who reported IPV in the previous year were asked about IPV services they received, about whether they exited their relationship, and about their physical health. Women reporting IPV who talked to their health care providers about relationship problems and violence were about 4 times more likely to receive IPV services compared to women reporting IPV who did not talk about the issue with their health care provider (OR=3.86). Those who received IPV services were more likely to exit the relationship compared to those who did not receive services (OR=2.62). Receiving more than one service or intervention nearly doubled the likelihood of exiting the relationship compared to receiving only one service. Those who exited the relationship reported better physical health than those who did not exit the relationship. A study of 265 KP Richmond women with IPV showed that a main reason for accepting mental health follow-up was that their physicians expressed concerned about stress-related symptoms associated with the abuse.

12 Intervention Makes a Difference!Women who talked to their health care provider about the abuse were nearly 4 times more likely to use an intervention I told my doctor I was feeling stressed out. She asked me if I was being abused. I said YES. And she told me about a group at Richmond Medical Center. I discovered I wasn’t the only woman this happens to. Now I feel so at peace, my life is better. B: This is a good time to hear from one of our members. Its important to know that most women end violent relationships. It takes time: on average 3-5 attempts and about 7 years The majority of women do not have recurrent abusive relationships https://youtu.be/q2GDQMOGQ5E Family Violence Prevention Program January 28, 2011 12

13 Affordable Care Act Screening and counseling for interpersonal and domestic violence included as part of women’s preventive health services Recommends universal screening for childbearing-age women IPV screening and counseling should be core part of women’s health services Women’s Preventive Health Care Services Committee

14 California State Law (AB890): Screening and TrainingSince 1995, California state law AB890 requires that health care providers routinely screen for IPV and that health care organizations train clinicians on detection and treatment because… Those experiencing IPV often seek medical care instead of contacting law enforcement Most women have regular contact with health care, providing multiple opportunities for learning about resources California State Law AB890: IPV Screening Recognizing that victims of domestic violence often seek medical care before calling the police, and that many physicians lack adequate training and guidelines to address domestic violence, AB 890 was introduced to the California legislature in 1993 and passed into law as Chapter 1234, effective July 1, This law amended code section of the Business and Professions Code and the Health and Safety Code as follows: Physicians, nurses and mental health professionals seeking licensure must demonstrate that training in domestic violence detection and treatment has been completed. Licensed clinics must establish and adopt written policies and procedures to screen patients for domestic violence. Polices are to include procedures to: Identify, through routine screening, victims and perpetrators of abuse Document injuries and illnesses attributable to domestic violence in the medical record Provide referrals for intervention Designate staff responsible for implementation and intervention as for the clinics. Hospitals are also required to have: Policies that address identification, documentation and intervention as for the clinics. In addition, hospitals must educate staff about criteria for identifying and procedures for handling domestic violence victims. Lastly, hospitals must advise domestic violence victims of available crisis intervention services.  This law carried no requirement for reimbursement for services rendered. Penalties for failing to comply are not defined in the law but failure to comply could affect licensing. The issue of civil liability for failure to screen must be considered.

15 California State Law (Penal Code 11160): ReportingHealth care providers are required to make a report to law enforcement if they are treating a physical injury due to IPV In California, health care providers are required to make a report to law enforcement when they provide medical services for a physical condition to a patient they know or suspect is suffering from a wound or physical injury due to assaultive or abusive conduct or a firearm. In 1995, the law clarified that injuries which result from assault by an intimate partner are included in the requirement. California State Law: Assault Reporting Who is required to report?: Any health practitioner is required to make a report if he or she "provides medical services for a physical condition" to a patient whom he or she knows or reasonably suspects is: (1) suffering from any physical injury inflicted by a firearm, and/or (2) suffering from other physical injury which is the result of assaultive or abusive conduct. "Assaultive or abusive conduct" includes a list of 24 criminal offenses, among which are murder, manslaughter, torture, battery, sexual battery, incest, assault with a deadly weapon, rape, spousal rape, abuse of spouse or cohabitant, and an attempt to commit any of these crimes. (Penal Code § 11160) Reporting procedure Telephone report immediately to jurisdiction where injury occurred Written report within 2 working days Documentation procedure and Use standard documentation form, Suspicious Injury Form OES See the KP internal website at: Additional resources, such as reporting forms, summary of the law, and FAQs regarding mandatory reporting can be found on the internal KP website: which can be accessed through the clinical library.

16 Most women consider the healthcare setting an appropriate place to discuss and seek help for IPV, and they want physicians to ask about IPV In a study of Kaiser Permanente members, 86% felt that all women should be screened for IPV, and 83% would advise others experiencing DV to seek help in the health care setting Many medical and professional guidelines describe a need for routine screening, and California State Law mandates it. However, many barriers to routine screening have been described, including clinicians’ fear of offending patients and their expectation that women would be reluctant to disclose abuse. Contrary to this concern, most women want physicians to screen for IPV. And about three out of four women say that if they had been victimized by IPV, they would be likely to disclose personal experiences to their health care professional. Clinicians need to bear in mind the many reasons (shame, guilt, concerns about confidentiality and safety) that a victim may choose not to disclose a history of abuse at initial inquiry and be prepared to inquire on multiple occasions. However, findings from a study of KP NCal members suggest that women health plan members consider the health care setting as an appropriate place to discuss and seek help for IPV.

17 It Starts with a Clear Goal: DV Inquiry and Intervention is Part of Everyday Work

18 Transforming the Healthcare ResponseInnovative “systems model” approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan Family Violence Prevention Program January 28, 2011

19 Kaiser Permanente’s Innovative Modelhttps://youtu.be/uocoMbCg9N8 Family Violence Prevention Program January 28, 2011

20 Clinician training modules Electronic Medical Record ToolsReferral Protocols Builds on existing resources in behavioral health, social services, mental health Clinician training modules Electronic Medical Record Tools Inquiry and Referral Supportive Environment Leadership and Oversight On-site Services Community Linkages McCaw, B., et al., Beyond screening for domestic violence: a systems model approach in a managed care setting. Am J Prev Med, (3): p Member and employee IPV education materials Ongoing work to establish and promote community resources 20

21 Supportive Environment Awareness and InformationWhat is it? Reaching patients everywhere they contact the health care system Information: restrooms, exam rooms, on-line, podcasts, health ed classes Posters: “Let us know, we can help” Private time with provider Engaged and informed workforce Family Violence Prevention Program January 28, 2011 21

22 Supportive Environment Patient Materials Rooming Alone22

23 Supportive Environment Privacy Posters Rooming AloneRooming alone allows for private discussions of sensitive issues, including relationship violence. 23

24 Must Address Clinician AND Patient ConcernsInquiry and Referral Must address patient AND clinician concerns The doctor: How do I ask about IPV? What do I do when the answer is “yes”? How can I offer an intervention that is caring, effective, and efficient? The patient: If I disclose, what will happen? Will I be able to access the next set of resources I need? How will this benefit my health?

25 Opportunities to reduce barriersExercise: Opportunities to reduce barriers

26 Inquiry and Referral What to do if the answer is “yes”?Role of the clinician is clear and limited ASK AFFIRM ASSESS DOCUMENT REFER “Making the right thing easier to do.” Family Violence Prevention Program January 28, 2011 26

27 Inquiry and Referral Supporting clinicians: Engaging patients:Using Technology to Improve Care Supporting clinicians: Tools in electronic medical record (EMR) Point-of-care online resources On-line clinician training Engaging patients: Online information for patients Advice Nurses, Call Centers Apps: Circle of 6, 1 Love, MyPlan Family Violence Prevention Program January 28, 2011 27

28 Domestic Violence Screening HealthConnect Questionnaire“Because violence is so common and it can affect your health, we ask all our patients about abuse. Your answers will be communicated to your provider.” 1. Within the past year, has your partner hit, slapped, kicked, or otherwise physically hurt you? Yes No 2. Within the past year, has your partner forced you to participate in unwanted sexual activities? 3. Are you afraid of your partner? Yes No

29 “Domestic Violence Screening Due”Improving IPV Inquiry Reminders embedded in Healthconnect “Domestic Violence Screening Due” Triggers in GYN POE Checklist Alert fires every 24 months Triggers in OB POE Checklist Alerts fire for pregnant women at gestational weeks 6-10, 24-28, and 36-37 Actions to be taken: Complete Domestic Violence Screening Questionnaire AND enter “Screening for Domestic Violence” code. Lyn: draft comments. Here is an example of how we are using a GYN DV Screening reminder into Obstetrics. Family Violence Prevention Program January 28, 2011

30 Improving Inquiry: Prenatal Intake QuestionnaireB: need content Family Violence Prevention Program January 28, 2011

31 Website easily accessible from EMR Provides Clinical Care Path

32 Clinician Training ResourcesHow to Ask, How to Respond, and How to Use HC Tools 14-min Online Training (2010) Clinician Tipsheet “Communicating with Patients: Intimate Partner Violence” (2012) A Provider’s Handbook on Culturally Competent Care Chapter: “Intimate Partner Violence” (2009) Making a Difference 6 min video (2013) Clinician training video Survivor Voices Stories of Courage, Hope, and Recovery (2016) Abuse and Assault Website Family Violence Prevention Program Intranet Site with clinical resources ( ) Family Violence Prevention Program January 28, 2011

33 Social Services & Mental HealthOn-site IPV Response Social Services & Mental Health Triage for other mental health conditions Danger assessment Safety plan Support groups Referral to community resources Family Violence Prevention Program January 28, 2011 33

34 On-site IPV Response HOW Options for HOW to do thisCustomize using local resources Local DV agency provides on-site advocate on-call response to hospital or clinic In house DV-trained staff collaborate w/ DV agency Private place to access help via phone or on-line Family Violence Prevention Program January 28, 2011 34

35 Community Linkages What are they? DV advocacy24-hour crisis response, safety planning Emergency shelter; transitional housing Other services: counseling, legal services, court advocacy National DV Hotline, Online Chat, Love is Respect Mobile Texting Family Justice Centers Family Violence Prevention Program January 28, 2011

36 Transforming the Healthcare ResponseInnovative “systems model” approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan Family Violence Prevention Program January 28, 2011

37 Outcome Measures for Initial Pilot Richmond CA medical center caring for 75,000 patientsPre and post survey of “systems model” Physicians: increased engagement, inquiry and referral 3 fold increase in identification and referral Patients- increase in IPV inquiry, increased satisfaction with healthplan Minimal impact on clinic workflow Minimal cost (using already available resources) “Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting,” McCaw B, Berman B, Syme L, Hunkeler E. American Journal of Preventive Medicine, 21(3), 2001. “Women Referred for On-site Domestic Violence Services in a Managed Care Organization,” McCaw B, Bauer H, Berman W, Mooney L, Holmberg M, Hunkeler E. Women and Health, 35(2-3), 2002. “Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting,” McCaw B, et al. American Journal of Preventive Medicine, 21(3), 2001. “Women Referred for On-site Domestic Violence Services in a Managed Care Organization,” McCaw B, et al. Women and Health, 35(2-3), 2002. Family Violence Prevention Program January 28, 2011

38 Initial success followed by implementation in 7 more facilitiesThis provided the opportunity to Incorporate new learnings Test patient educational materials Revise clinician training Define qualitative and quantitative metrics Identify the tools needed to support clinician champions and multi-disciplinary teams. B: new learnings- some facilities didn’t have social workers, role of nurses varied. ED had different needs, Gaps in MH response, challenges of partnering with community advocacy. Family Violence Prevention Program January 28, 2011

39 Next step: Scaling up Infrastructure and sponsorship at each medical center Step-wise implementation of System Model Tools for implementation teams Champion and Team roles Templates for referral pathway Clinician and patient education Regular communication with facility based teams Quality improvement measures Executive Regional sponsorship

40 Phases of ImplementationEach element has value, so any steps can be useful in moving forward. The biggest impact comes from doing something from each element.

41 Step-wise ImplementationForm a local multi-disciplinary team with clinician champion Develop protocol for patients in urgent and non-urgent situations Identify community resources and develop partnerships Step 2 Visible patient education materials Ensure that on-site services are in place Choose quality measures and annual goals Stakeholder communication and engagement Family Violence Prevention Program January 28, 2011 41

42 Step-wise ImplementationClinician training- brief, frequent. Include tools and stories. Trend progress over time DV resources for employees Step 4 Leadership training for champion and teams Link to other initiatives- electronic medical record, chronic conditions Sustain partnerships with community advocacy Highlight ‘promising practices’ Stakeholder communication and engagement Family Violence Prevention Program January 28, 2011 42

43 How can we measure our workExercise: How can we measure our work

44 Transforming the Healthcare ResponseInnovative “systems model” approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan Family Violence Prevention Program January 28, 2011

45 Process Measures have valueFor example… Each medical center has: Physician champion for IPV Multi-disciplinary team to implement the model Protocol for referral to mental health Highlights essential infrastructure element Family Violence Prevention Program January 28, 2011

46 Family Violence Prevention Program January 28, 2011B- these are examples of other kinds of things that are meaningful and amenable to Process Measures Family Violence Prevention Program January 28, 2011

47 KP Quality Improvement (QI) MeasuresUses automated database Makes sense clinically Actionable Linked with national standard National Committee for Quality Assurance (NCQA): “QI 11 – Demonstration of a health program showing continuity and coordination between medical and behavioral health care.” 47

48 KP Northern California: 25-fold Increase in IPV Identification25,275 Family Violence Prevention Program January 28, 2011

49 KP Southern California: Female Members Diagnosed with IPV Regional, all depts, Females age 18-65

50 How to ensure success as our program growsExercise: How to ensure success as our program grows

51 Transforming the Healthcare ResponseInnovative “systems model” approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan Family Violence Prevention Program January 28, 2011

52 Performance ImprovementLearning from “high performers” Identifying innovation and promising practices Use of Plan-Do-Study-Act (PDSA) Disseminating best practices Using the established workplace tools (such as EMR) Aligning with other initiatives and strategic goals (reducing disparities, patient safety, care coordination)

53 Learning from high performersFamily Violence Prevention Program January 28, 2011

54 Example of an innovation that became a best practice: IPV screening tool + private time with provider Family Violence Prevention Program January 28, 2011

55 Depression and Anxiety Screening Tool includes IPVUsing established tools, aligning with other initiatives: Depression and Anxiety Screening Tool includes IPV Family Violence Prevention Program January 28, 2011

56 Transforming the Healthcare ResponseInnovative “systems model” approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan Family Violence Prevention Program January 28, 2011

57 Implementation of IPV Services Underway in Every KP RegionWashington Northwest Northern California Colorado Mid-Atlantic Southern California And where are we now? I am proud to say that we have efforts underway in almost every KP region. Georgia Hawaii Family Violence Prevention Program January 28, 2011 57

58 Inter-regional Family Violence Prevention ChampionsStarted in 2007 Adoption of Systems Model approach Health Connect tools Clinical recommendations and workflow Clinical resources (clinician training, patient education materials) Sharing best practices Presentations at National conferences Inclusion of other forms of family violence TDV, EA, CA, and now ACES/TIC B: need content and now Common Metric Partnership w/ Ob/gyn IR Chiefs Family Violence Prevention Program January 28, 2011

59 IPV Screening WorkflowB: need content Family Violence Prevention Program January 28, 2011

60 Overview of DV SmartSet ContentsThe DV smart set includes : DV questionnaire (and danger assessment) smart phrases for progress notes; dVw/without injury, AVS. Family Violence Prevention Program January 28, 2011

61 Patient Education ResourcesB: need content Family Violence Prevention Program January 28, 2011

62 Regional Intranet Sites with Clinical ResourcesMid-Atlantic Hawaii NCAL B: need content Family Violence Prevention Program January 28, 2011

63 Accomplishments and Goals by RegionColorado Implementing Domestic Violence Screening and rooming alone in all OB/GYN Clinics DV assessment Smartset, and clinical DV toolkit Rooming alone pilot in primary care Metrics: Health Plan Primary Care Dashboard in 2015 Hawaii DV screening in OB, revised prenatal intake Med/Legal Newsletter on DV Teen dating violence questions on adolescent questionnaire Metrics: Womens Health Northwest Active support from Primary Care Chief Identified and engaged new DV Physician Champion Continued collaboration w/ social services and health education Georgia Active support from Ob/gyn Chief Active collaboration w/ advocacy organization B: Review content

64 Accomplishments and Goals by RegionMid-Atlantic States Comprehensive prenatal program including IPV and Early Start services and follow-up Training for nurses to provide brief IPV intervention Metric: Women’s Health Dashboard Participation in Maryland Hospital IPV Consortium Southern California Implementation of OB/GYN IPV Prenatal Screening throughout the region GYN Proactive Office Encounter (POE) includes DV screening Family Violence Symposium Metric: KPHC Physician Dashboard Northern California Rooming alone and DV screening in OB/gyn dept, some AFM and ED. . Metrics: meets NCQA standard, WH Dashboard, MGA dashboard, data for Medicine, MH, ED. Clinician specific dx data B: Need to revise this slide. Also needs content

65 2016 Inter-regional Quality Improvement Metric: IPV Identification RateApproximately 1.3 million adult women visit KP’s OB/Gyn clinics annually. At least 4% are currently experiencing IPV (approximately 52,000 women members). This data shows the IPV identification rate for 2016. CO: 5.1% (82/1,617) HI: 1.5% (16/1,100) NW: 2.9% (39/1,357) GA: 0.9% (14/1,638) SC: 1.8% (230/12,527) NC: 45.6% (9,620/21,091) # of women with IPV Dx # of women with current IPV* *estimated using a 4% prevalence for adult women B: need addtl content. In 2015, the IPV Inter-regional group began to consider how a common metric might help inform and catalyze the work that was underway in the regions and requested some national analytic resources to explore this further. Here is the metric that was developed as a result of that process. It focuses on identification of IPV based on documentation in the diagnosis section of HC. That is the numerator. The denominator is an estimate to the number of KP women currently experiencing physical IPV. This estimate is based on multiple sources- both external and internal, and represents a low end estimate. The prevalence rate is applied to the number of women who have made a visit to the Ob/gyn dept in that region. IPV Identification Rate =

66 © 2017 National Quality Conference  © 2017 Kaiser Foundation Health Plan, Inc.  For internal use only.IPV Identification Rate by Region, 2014Q Q4 Among Women Age Seen in OB/Gyn Department 5.1% 2.9% 1.8% This is another way of displaying that information. Ncal data which you have already seen is not on this graph. Its not surprising that the regions are low, this is what Ncal looked like in the first 8 years of collecting and beginning to use the data, developing local teams, and fully implementing the systems model in all facilities. 1.5% 0.9% Numerator: Women with IPV Dx Denominator: Current Prevalence Estimate (4% of Women Members SEEN IN OBGYN)

67 Vision Kaiser Permanente will be the leader in transforming the healthcare response to interpersonal violence and abuse and A vital partner in community and national efforts to end violence

68 Vision for 2020 Links between multiple forms of violenceTrauma informed care Resiliency and strengths based approaches Essential role of community partnerships 2-Generation perspective Collaboration across departments Looking toward the future: themes that will be informing our family violence program work over the next 3 yrs.

69 We believe that total health is more than freedom from physical affliction— it’s about mind, body, and spirit. L - Fix photo Family Violence Prevention Program January 28, 2011

70 © 2017 National Quality Conference  © 2017 Kaiser Foundation Health Plan, Inc.  For internal use only.Q+A

71 Contact Information Liza Eshilian-Oates, MD Physician Leader, Family Violence Prevention Program Kaiser Permanente- SCAL kp.org/domesticviolence Family Violence Prevention Program January 28, 2011

72 Appendix

73 Key References Young-Wolff K, Kotz K, McCaw B (2016) Transforming the Health Care Response to Intimate Partner Violence: Addressing “Wicked Problems”. Journal of the American Medical Association. 315(23): Chapter 35: Intimate Partner Violence in King T, et al. ed. (2016) Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2nd Edition. Babaria P, McCaw B, Kimberg, L. Miller E, McCaw B, Humphreys B, Mitchell C (2015) Integrating Intimate Partner Violence Assessment and Intervention into Healthcare in the United States: A Systems Approach. Journal of Women’s Health. 24(1): 92-99 Decker M, Frattaroli S, McCaw B, et al (2012) Conference proceedings: Transforming the Health Care Response to Intimate Partner Violence and Taking Best Practices to Scale. Journal of Women’s Health 21 (12) IOM Member Spotlight. Violence Prevention: The Role for Health Systems (2012) IOM (Institute of Medicine) Forum on Global Violence Prevention. Washington, DC Family Violence Prevention Program January 28, 2011

74 Descriptions of the KP Systems-Model Approach"Using a Systems-Model Model approach to Improving IPV Services in a Large Health Care Organization". Institute of Medicine. 2011 Children-Workshop-Summary.aspx“ “Developing a Health System Response to Intimate Partner Violence,” McCaw, B, and Kotz, K, Intimate Partner Violence: A Health-Based Perspective, C. Mitchell and D. Anglin ed., Oxford University Press 2009 AHRQ Innovations Solution: “Family Violence Prevention Program significantly improves ability to identify and facilitate treatment for patients affected by domestic violence,” AHRQ Tool for Assessment of Health System Response Kaiser Permanente Domestic Violence website kp.org/domesticviolence Family Violence Prevention Program January 28, 2011

75 Journal of the American Medical Association (JAMA) June, 2016https://share.kaiserpermanente.org/article/fast-facts-about-kaiser-permanente/ Journal of the American Medical Association (JAMA) June, 2016 Family Violence Prevention Program January 28, 2011

76 Addt’l KP Research Publications on DVA Description of Midlife Women Experiencing Intimate Partner Violence using Electronic Medical Record Information. (2016) Journal of Women’s Health. 25 (5) Eaton A, Temkin T, Fireman B, McCaw B, Kotz K, Amaral D, Bhargava R. Minority Women with HIV or AIDS May Suffer From Violence at the Hands of Intimate Partners, Delaying Necessary Treatment. An interview with Brigid McCaw MD (2015) Kaiser Permanente Institute for Health Policy. Nov.30, Lee S. “A Predictive Model to Help Identify Intimate Partner Violence Using Diagnoses and Phone Calls,” Barghava R, Temkin TL, Fireman BH, Eaton A, McCaw B, Kotz KJ, Amaral D. American Journal of Preventive Medicine, 2011. “Mental Health Service Referral and Utilization among Women Experiencing Intimate Partner Violence,” Ahmed A, McCaw B. Am J of Managed Care, 2010. Family Violence Prevention Program January 28, 2011

77 “Intimate Partner Violence,” McCaw, B“Intimate Partner Violence,” McCaw, B., A Provider’s Handbook on Culturally Competent Care: Women’s Health, Kaiser Permanente National Diversity Council and Office 2009 “Domestic Violence and Abuse, Health Status, and Social Functioning,” McCaw B, Golding B, Farley, M, Minkoff J. Women and Health, 45(2), 2007. “Family Violence Prevention Program: Another Way to Save a Life,” McCaw B, Kotz K.The Permanente Journal 9(1), 2005. “Women Referred for On-site Domestic Violence Services in a Managed Care Organization,” McCaw B, Bauer H, Berman W, Mooney L, Holmberg M, Hunkeler E. Women and Health, 35(2-3), 2002. “Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting,” McCaw B, Berman B, Syme L, Hunkeler E. American Journal of Preventive Medicine, 21(3), 2001. L please format Family Violence Prevention Program January 28, 2011

78 Kaiser Permanente (KP)Largest, non-profit health plan in United States 10.6 million members nationally serves 7 states and District of Columbia 18,652 doctors; 194,294 employees KP Southern California Region 4 million+ members 7,000+ doctors 14 hospitals 222 outpatient facilities/offices https://share.kaiserpermanente.org/article/fast-facts-about-kaiser-permanente/

79 Health Care Utilization Among Complex and Costly KPNC Members: Barriers and FacilitatorsProject Team: Stacy Sterling, Alix Pruzansky, Sandy Bui & Felicia Chi, with Richard Grant, Connie Weisner, and Andrea Altschuler. Editorial consultation and bibliographic assistance from Aggie Hinman and Alison Truman. The DOR study of high utilizers examined what differentiates high cost members from lower cost members, controlling for medical severity and demographic factors. Findings: Behavioral health was the dominant theme among the high utilizers, a major factor influencing health care utilization and health outcomes. Domestic violence was a significant predictor of high utilization status. A history of adverse childhood experiences (ACEs) predicted not only health problems, which has been well-established in the literature, but also health care costs, even when controlling for medical severity and other factors. Recommendation: The independent effects on costs, of both domestic violence and adverse childhood experiences, controlling for other factors, suggests the value of better screening, assessment and trauma-informed treatment. For internal informational use only. This study has not been released. New Data from DOR. Not yet released or published. Commissioned by Dr. Pearl and Madvig to try and understand more about factors (social and behavioral health determinants) that differentiate those patients w/ complex conditions who are very high utilizers.

80 IPV & sexually transmitted infections (STI’s)Women disclosing physical abuse were 3 times more likely to experience an STI. Women disclosing psychological abuse were 2 times more likely to experience an STI. Past-year prevalence of physical and/or sexual IPV among women seeking abortion is 14-21%. Lifetime prevalence of physical and/or sexual IPV among women seeking abortion is 27-40%. IPV & pregnancy termination For additional information on the health effects of forced sex, refer to the section on women’s health In the Coker et al. (2000) study, the relative risk (RR) of physically abused women experiencing a STI was 3.13 compared to non-abused women. The relative risk of psychologically abused women experiencing a STI was 1.82. RR is the abbreviation for relative risk. Relative risk is defined as the incidence rate for persons exposed to a factor compared to the incidence rate for persons not exposed to that factor. In this study, the factor or exposure is domestic violence and the incidence rate of sexually transmitted diseases is compared among women who have disclosed domestic violence compared to women who did not disclose a history of domestic violence. (Mausner & Kramer, 1985) Lifetime: Evins et al, 1996; Glander et al, 1998; Keeling et al, 2004; Leung et al, 2002 Past Year: Evins et al, 1996; Keeling et al, 2004 ; Woo et al, 2005; Weibe et al, 2001; Whitehead & Fanslow, 2005 Glander et al, (1998) reported that women with a history of abuse reported relationship issues as the sole reason for pregnancy termination more often than women who did not disclose a history of abuse. Leung et al, (2002) interviewed women seeking termination of pregnancy at a hospital in Hong Kong and a comparison group of non-abortion seeking, general gynecology patients. The prevalence of lifetime IPV was 27.3% among women seeking abortions compared to 8.2% among non-abortion seeking, general gynecology patients More than 25% of abortion-seeking patients indicated that their decision for termination of pregnancy had been affected by their experience of abuse Abortion seeking patients reported more serious physical injuries from abuse compared to non-abortion seeking, gynecology patients who also disclosed abuse Whitehead and Fanslow (2005) conducted a survey with 218 women seen at an abortion clinic. In the past year, nearly 1 out of 10 (8.5%) had experienced sexual abuse. 80 Coker et al, 2000 Family Violence Prevention Program January 26, 2011 80

81 IPV and Chronic Health ProblemsMAKING THE CASE IPV and Chronic Health Problems Center for Disease Control (CDC) Feb 2008 60% more likely to have asthma 70% more likely to have heart disease 80% more likely to have a stroke Twice as likely to be a current smoker Family Violence Prevention Program January 28, 2011 81 81

82 Coding for IPV Adult abuse (physical, emotional, or sexual)Spouse or partner violence (physical or sexual) Spouse or partner abuse (emotional) Hx of spouse or partner violence (physical or sexual) Hx of spouse or partner abuse (emotional) Adolescent relationship abuse (physical, emotional) There are a large number of ICD-10 codes for current or past history of IPV. The ones in this slide illustrate the key recommended diagnostic choices. Family Violence Prevention Program January 28, 2011

83 37, 219 KP Patients Identified with IPV Additional Information: Ethnicity ▪ Language ▪ Length of Kaiser membership ▪ Smoking status ▪ BMI ▪ Pregnancy within 2 years of IPV diagnosis