Medical College of Wisconsin Health Care Can Change from Within: A New Model to Improve the Prevention and Treatment of Intimate Partner Violence L. Kevin Hamberger, Bruce Ambuel, PhD, PhD, Marlene Melzer, MD, Mary Beth Phelan, MD & Amy Kistner, MS, Clare Guse, MS Medical College of Wisconsin

Overview The Healthcare Can Change from Within Model Changing Clinic Systems: Results Helping Battered Women: Early Results

Healthcare Can Change From Within Academic-Community Partnership Funded by a grant from the Healthier Wisconsin Partnership Program

IPV is a health care issue

Models of change Key leaders (surgeon general) Professional associations Regulatory: JCAHCO Mandatory CME Education -- the black box model Collaboration with community advocates Policies and procedures

Failure to bring about sustained change Lessons from McCleer & Anwar and associates

Healthcare Can Change From Within

What Multi-dimensional Training & education Systems change Policies and procedures Protocols Chart prompts Patient environmental changes Collaborative Multidisciplinary

… Harness internal expertise to change and sustain healthcare culture that values and responds to IPV as a health issue Emphasizes IPV as a health care problem Public health issue-primary prevention Medical problem w/ health consequences: intervention/secondary prevention Cost effective

Key Features: Total system change Develop on-site healthcare advocates Saturation training of all staff—everyone has a role Policies and procedures for screening, documentation, intervention and prevention Creating a trauma sensitive environment

Health care advocate training In depth 20 hours Modeled on DV advocacy training Health care systems change added Time commitment 4 hours per week during intensive staff in-services 1-2 hours per week after training

Health Care Can Change from Within: Change in Health Care Systems Bruce Ambuel, PhD, L. Kevin Hamberger, PhD, Clare Guse, MS, Amy Kistner, MS, Marlene Melzer, MD & Mary Beth Phelan, MD Medical College of Wisconsin

Research Design: Clinic Change Site Pre Post Pediatric Clinic X Emergency Department 2 Family Medicine Clinics 2 Family Medicine Control Clinics --- Pre/post in 4 intervention sites ---/post in 2 control sites Each intervention clinic is it’s own control 2 family medicine intervention clinics compared vs. 2 family medicine control clinics

Key Variables Clinic Environment Staff Knowledge & Attitudes Documentation of Screening Patient Post-Visit Survey

Clinic Environment Environmental Audit modified from Coben (Measuring the Quality of Hospital-based Domestic Violence Programs, Coben, J AEM 2002) Physical Environment Poster & brochure Referral information Other language(s) System Policies and Procedures Written Policy & Procedure Screening of specified patients?

Physical Environment 3 4 1 (65 sites) (105 sites) Baseline n=4 Intervention Posters& Brochures 3 (65 sites) 4 (105 sites) Referral Information 1 Non-English Material Change over time in 4 intervention clinics—1 pediatrics; 2 family medicine; 1 emergency medicine.

Policies, Procedures, Collaboration Baseline n=4 Intervention IPV Policy & Procedure 1 3 Screening of Specified Pts. Community Collaboration 2 4 Change over time in 4 intervention clinics—1 pediatrics; 2 family medicine; 1 emergency medicine.

Family Medicine Clinics: Usual Care vs. Change from Within Physical Environment Usual Care n=2 Change from Within n=2 Posters& Brochures (0 sites) 2 (45 sites) Referral Information Non-English Material Comparison of 2 Change from Within family medicine clinics with 2 usual care control clinics.

Family Medicine Clinics: Usual Care vs. Change from Within Policy, Procedure, Collaboration Usual Care Clinic n = 2 Change from Within Clinic Clinic Policy 2 Screening Collaboration Comparison of 2 Change from Within family medicine clinics with 2 usual care control clinics.

Chart Audit: Screening for IPV Year YES Screening NO Screening 2005 30% (24) 70% (55) 2006 42% (32) 58% (45) 2008 60% (49) 40% Chart audit of charts from 2 family medicine clinics and emergency department. Pearson chi2(2) = 15.0466 Pr = 0.001

Health Care Can Change from Within: Helping Survivors—Early Findings L. Kevin Hamberger, Bruce Ambuel, PhD, PhD, MS, Clare Guse, MS, Marlene Melzer, MD Mary Beth Phelan, MD & Amy Kistner, Medical College of Wisconsin

Research Design: Longitudinal Quasi-experimental 2 intervention family medicine clinics Healthcare can change from within 2 control family medicine clinics Usual practice

Project Purpose is to Evaluate: IPV prevention-related environmental changes as a result of intervention IPV screening rates between intervention and control clinics Victims’ consumer feedback about benefits and potential harms of IPV screening in healthcare setting Changes in: violence victimization and safety in intervention and control clinic patients victim’s knowledge and utilization of resources in intervention and control clinics physical and mental health status of IPV victims in intervention and control clinics

Method Recruitment Follow-up assessment 3, 6, 12, 18 months

Instruments Used CTS-2 DAS Medicare Health Outcome Survey – adapted CDC Healthy Days Core & Symptom Modules Patient Safety and Connection to the Community Chart audit Clinic environmental audit Physicians and Nurses Asking about IPV

Clinic Characteristics – Payor Mix Intervention % Medicare: 17 Medicaid: 42.5 Commercial: 9.5 HMO: 5.5 Self pay: 23.5 Other: 2 Usual Care % 17 61.5 7 1

Very Preliminary Results

Participants Follow-ups completed Time 1: post-intervention: 35 (20 intervention; 15 usual care) Time 2: 3-months: 28 Time 3: 6-months: 26 Time 4: 12-months: 8

Pre-Intervention Violence Exposure (CTS-2) Negotiation 100 Psych. Abuse 100 Coerced Sex 95 Physical Abuse 100 Injured 95 USUAL CARE % 100 93

Comparative Screening Rates at 3 months (based on participant self report) Screened (%) Yes No Intervention (n = 16) 75 25 Control (n = 11) 18 82

Benefits and Potential Harms of Screening How helpful is it for a doctor or nurse to ask about IPV? 67% stated it is very helpful or helpful 26% stated they were unsure if screening is helpful 7.4% stated that it was not at all helpful

How harmful is it for a doctor or nurse to ask about IPV? 67% stated it was definitely not harmful or not harmful 33% stated they were unsure if screening was harmful 0% stated that screening was harmful

Should doctors and nurses ask about IPV? 77.7% stated providers definitely should or should ask 11% stated they were unsure if providers should ask 7.4% stated providers should not ask about IPV

Future Directions & Discussion