Prevention Against Violent Experiences (PAVE) Successes and Barriers in the Implementation of Computerized Screening

AUTHORS Lise E. Fried, DSc, MS,1 Megan Gerber, MD, MPH,2 Elizabeth Claggett-Borne, LMFT, MEd,3 Emily Chiasson, MSW, MPH,1,3 Yadira Ramos,3 Omonyele Adjognon, MPH,1 Alice Verhoeven, MS,3 and Kathleen Harney, MD3 1Institute for Community Health 2Veteran’s Administration 3Cambridge Health Alliance

Outline Background on screening and intervention PAVE: primary goals Computerized screening tool Implementation Screening results Challenges and successes

Background Screening for DV is controversial Up to 50% of primary care patients have a lifetime prevalence of DV Boston OB/GYN patients have a 12.7% annual prevalence and 35% lifetime prevalence of DV Screening rates for DV remain low in health care settings Research into screening strategies for vulnerable/underserved populations lacking Alternative screening methods effective

PAVE Primary Goals Increase DV screening and detection rates by: Improving standardization of screening Developing and piloting a computerized DV tool Provide follow-up intervention for DV victims Focus on under-served victims Provide DV response training for health care providers and clinic personnel Funding: 3 Yr VAWA STOP Grant (2005-2008) through the Massachusetts Executive Office of Public Safety and Security (EOPSS) Private donors Cambridge Health Alliance

PAVE Activities Train clinic staff about DV Develop computerized screening tool Do baseline medical record review on screening Hire part time DV advocate

Computerized Screening Allows patients to self-disclose DV confidentially Can be used for health education Well-suited for low-literacy populations Can be translated into multiple languages to serve diverse populations Generates reports that can guide providers - focus on assessment, counselling, and referrals

The Computerized DV Screening Tool Created using Authorware software Touch screen computers Takes 5-10 minutes to complete Implemented in 4 languages: English, Haitian Creole, Spanish, and Portuguese Audio-recorded feature All responses collected in database Automatic printout generated at end of screening for provider review

Implementation Started in September 2007 in 1 clinic Second clinic added in May 2008 Chief of OBGYN piloted Rolled out to all providers in both clinics

Results

Results of Baseline Medical Record Review Clinic 1: Sept – Dec 2005, Clinic 2: March to December 2006 873 valid records – 505 people 15.5% screened 9.0% current DV 20.5% lifetime DV

Medical Record Review: Screened vs. Not Screened One clinic more likely to screen (19% vs. 11%)GYN More likely to get screened prenatally than at a GYN visit (24% vs. 13%) Nurses more likely to screen than MDs (24% vs. 11%)

Screening Data Roll-out: Clinic 1 - Sept 2007, Clinic 2 - May 2008 Data through April 7, 2009 300 screens in Clinic 1 (90%, n=271, completed) 57 screens in Clinic 2 (91%, n=52 , completed) 9.5% of women refused to continue with screening

Screening Trends at Clinic 1 After peaking in May 2008, there has been a significant decrease in the number of women screened. Screening rates in January through March of 2009 are similar to those in 2008

Screening Trends at Clinic 2 Screenings in clinic 2 peaked at start up in May 2008 but experienced a significant decline in the number of women screened by December 2008. In January 2009, screening prevalence was at almost half of what it was at start up in May 2008, and further declined in March.

Screenings: Patient Demographics   Site Clinic 1 Clinic 2 Number Percent Type of Visit GYN 257 85% 44 77% Post Partum 7 2% 2 3% Pre Natal 36 12% 11 19% Language English 220 73% 20 35% Spanish 30 10% 6 Portuguese 47 15% 52% Haitian Creole 3 1% 1

Domestic Violence Positive Patients by Type of Visit Clinic 1: 65 women screened positive (24% ) Clinic 2: 8 women screened positive (15% )

Domestic Violence Positive Patients by Language

Domestic Violence Positive Patients 15-24% of the women report DV Approximately 1/2 DV+ women report current experience of DV ( in the past year) About 12% of DV+ women request to speak to advocate at clinic 1 About 37% of DV+ women request to speak to advocate at clinic 2

Satisfaction with Screening Tool   Positive Screen No Yes Percent How comfortable did you feel answering questions on this computer? Not comfortable 1% Somewhat comfortable 8% 30% Very comfortable 90% 69% How comfortable did you feel answering to these questions here in the exam room? 4% 5% 24% 94% 71% How easy was it to understand the information given to you today? Somewhat easy Very easy 98% 95%

PAVE: FAST TRACK Report Clinics 1 & 2

Challenges & Successes DV screening one more task for MAs and providers Introducing screening tool to patients difficult Availability of DV advocate Sustainability Success: Patients like and trust computerized screening Standardized screening More patients being educated about DV DV patients seen by advocate

Next Analyses Are more women being screened? Is more DV being detected? Is advocacy/intervention making a difference?

Acknowledgements Cambridge Health Alliance WHC provider teams at the clinics Patients at the clinics ICH Data and Evaluation Team Victims of Violence Program Yadira Ramos, screening tool developer, Community Affairs Department Megan Gerber, MD, MPH EOPSS and private donors

Any questions or comments?