1. Brigid McCaw, MD, MPH, MS, FACP Medical Director, Family Violence Prevention Program Kaiser Permanente California, USA Royal Commission into Family Violence Victoria, Australia May 2016 Transforming the Health Care Response to Family Violence

2. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Inquiry and Referral Supportive Environment Leadership and Oversight On-site Services Community Linkages Patient and employee IPV education materials Ongoing work to establish and promote community resources Medical Record Tools Clinician training modules Builds on existing resources in social services, mental health Referral Protocols 22

3. KP Northern California: Eighteen-fold Increase in IPV Identification 3

4. KP Northern California: Most Identification Occurs in Ambulatory Care Primary Care Mental Health ED and Urgent Care 4

5. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Supportive Environment Awareness and Information Information and Resources  Everywhere patients contact the health care system: exam rooms, restrooms, waiting areas  Posters: “Let us know, we can help”  Brochures, health education classes, podcasts, online Engaged and informed workforce 5

6. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Supportive Environment Patient Education Materials 6

7. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Rooming Alone Rooming alone allows for private discussions of sensitive issues, including relationship violence. Supportive Environment Privacy Posters 7

8. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Must Address Clinician AND Patient 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? Inquiry and Referral Must address patient AND clinician concerns 8

9. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. 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.” 9

10. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Website with Clinical Care Path 10

11. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. IPV Screening Tool used in some clinics 11

12. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Depression Screening 12

13. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. On-site IPV Response  Triage for other mental health conditions  Danger assessment  Safety plan  Support groups  Referral to community resources Social Services & Mental Health 13

14. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. What are they?  DV advocacy  24-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 Community Linkages 14

15. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Rapidly Spreading What Works… …and Sustaining It  Infrastructure and sponsorship at each medical center  Tools for implementation teams  Champion and Team roles  Templates for referral pathway  Clinician and patient education  Quality improvement measures  Step-wise implementation  Regular communication with teams 15

16. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Step-wise Implementation Step 1  Form 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 16

17. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Step-wise Implementation Step 3  Clinician 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 17

18. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. The KP Systems-Model Approach Inquiry and Referral Supportive Environment Leadership and Oversight On-site Services Community Linkages “Making the right thing easier to do” 18

19. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Transforming the Health Care Response to Family Violence 19

20. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Contact Information Brigid McCaw, MD, MS, MPH, FACP Medical Director, Family Violence Prevention Program Kaiser Permanente @BrigidMcCaw Brigid.McCaw@kp.org kp.org/domesticviolence 20

21. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Appendix 21

22. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Descriptions of the KP Systems-Model Approach  “Transforming the Healthcare Response to Intimate Partner Violence: Addressing ‘Wicked Problems,’” Young-Wolff KC, Kotz K, McCaw B. JAMA, 2016 (in press).  “Integrating Intimate Partner Violence Assessment and Intervention into Healthcare in the United States: A Systems Approach,” Miller E, McCaw B, Humphreys B, Mitchell C. Journal of Women’s Health, 2015  “Transforming the Healthcare Response to Intimate Partner Violence and Taking Best Practices to Scale,” Decker M, Frattaroli S, McCaw B, et al. Journal of Women’s Health, 2012.  “Transforming the Health Care Response to Domestic Violence,” Kaiser Permanente Institute for Health Policy. Kaiser Permanente Policy Stories, 2012. Vol. 1, No. 10. http://kpihp.org/wp-content/uploads/2013/10/KPStories-v1-no10-DomesViol-FINAL-10-07-13.pdf http://kpihp.org/wp-content/uploads/2013/10/KPStories-v1-no10-DomesViol-FINAL-10-07-13.pdf  “Using a Systems-Model Model approach to Improving IPV Services in a Large Health Care Organization”. Institute of Medicine. 2011 http://www.iom.edu/Reports/2011/Preventing-Violence-Against-Women-and-Children-Workshop- Summary.aspx 22

23. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Descriptions of the KP Systems-Model Approach (cont’d)  “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  Agency for Healthcare Research and Quality (AHRQ) Innovations Solution: “Family Violence Prevention Program significantly improves ability to identify and facilitate treatment for patients affected by domestic violence,” http://www.innovations.ahrq.gov/content.aspx?id=2343 http://www.innovations.ahrq.gov/content.aspx?id=2343  AHRQ Tool for Assessment of Health System Response http://www.ahrq.gov/research/domesticviol/ http://www.ahrq.gov/research/domesticviol/  Kaiser Permanente Domestic Violence website kp.org/domesticviolence 23

24. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. KP Research Publications on DV  “A Description of Midlife Women Experiencing Intimate Partner Violence Using Electronic Medical Record Information” Eaton A, Temkin T, Fireman B, McCaw B, Kotz K, Amaral D, Bhargava R. Journal of Women’s Health, 25(5), 2016.  “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.  “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. 24

25. © 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. KP Research Publications on DV  “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. 25