1. 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

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

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

4. IPV is a health care issue

5. 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

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

7. Healthcare Can Change From Within

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

9. …
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

10. 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

11. 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

12. 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

13. 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

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

15. 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?

16. 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.

17. 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.

18. 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.

19. 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.

20. 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) = Pr = 0.001

21. 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

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

23. 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

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

25. 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

26. Clinic Characteristics – Payor Mix
Intervention %
Medicare:
Medicaid:
Commercial:
HMO:
Self pay:
Other:
Usual Care % 17
61.5 7 1

27. Very Preliminary Results

28. 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

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

30. Comparative Screening Rates at 3 months (based on participant self report)
Screened (%) Yes No
Intervention (n = 16)
Control (n = 11)

31. 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

32. 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

33. 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

34. Future Directions & Discussion