The high prevalence of intimate partner violence (IPV) has led to recommended screening for all women of child-bearing age. Implementing validated screening tools within routine wellness visits at primary care offices facilitates awareness and patient support through identification and resource referral.https://scholarworks.uvm.edu/fmclerk/1537/thumbnail.jp

Churchill, Alexandra E

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UVM ScholarWorks

University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2019Intimate Partner Violence: Improving ScreeningRates in the Primary Care SettingAlexandra E. ChurchillUniversity of VermontFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Medical Education Commons, and the Primary Care CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationChurchill, Alexandra E., "Intimate Partner Violence: Improving Screening Rates in the Primary Care Setting" (2019). Family MedicineClerkship Student Projects. 475.https://scholarworks.uvm.edu/fmclerk/475INTIMATE PARTNER VIOLENCE: IMPROVING SCREENING RATES IN THE PRIMARY CARE SETTINGNewtown Primary CareLexi ChurchillRotation 1 - April 2019Dr. Eurica ChangPROBLEM IDENTIFICATION AND DESCRIPTION OF NEEDIntimate partner violence (IPV) is defined by the CDC as “physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner”1❖ National data (2015) indicate 1 in 4 women and 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking with subsequent IPV-related impact2❖ Greater than one-third of both women and men have experienced psychological aggression alone2❖ 71.1% of female victims and 55.8% of male victims first experienced IPV before age 252❖ Domestic violence agencies across Connecticut provided services to 38,192 victims in 20183❖ Though the U.S. Preventative Services Task Force recommends screening all female patients of childbearing age for IPV3, primary care provider implementation rates are low4❖ Within the Western Connecticut Health Network EMR, none of the publicly available “Wellness Visit” templates include IPV screening, nor is there a separate IPV screening templatePUBLIC HEALTH COST❖ Outside of direct physical injury, IPV is associated with numerous medical conditions including cardiovascular disease, CNS and GI disorders, chronic pain syndromes, anxiety, depression, and PTSD1❖ Victims of IPV are at increased risk of miscarriage, preterm labor, STIs, high-risk sexual behavior, homelessness, substance abuse, poor nutrition, alcoholism, and suicide1❖ One study estimated the lifetime economic burden of IPV victims, both male and female, to be nearly $3.6 trillion, of which $2.1 trillion (59%) came from medical costs5❖ Under-reporting of IPV by victims indicates the actual costs are likely even higherCOMMUNITY PERSPECTIVENya Rossi, PA Newtown Primary CareWhat are the barriers facing patients to disclose IPV to their primary care provider?Fear. Of my patients that are known victims of IPV, their partners usually come to the office visits, making it difficult to directly ask the patient about IPV or to offer resources discretely.What other barriers keep providers from asking screening IPV questions?It is uncomfortable to ask. I was trained to ask 'Do you feel safe in your relationship?', but that doesn't seem adequate and wording can be difficult with such a sensitive topic. I should be asking it more often though. Including a well-worded, one-question screen in annual visits would be a great way to ensure the question gets asked.LCSW Western Connecticut Health NetworkWhat is your perspective of IPV screening during routine office visits?It’s absolutely necessary, it helps normalize the question and provides an avenue for victims to safely disclose without fear of repercussions. Though it can be a tough question to ask because it seems so direct, so it’s probably not happening enough. I will see patients for one mental health issue – depression, anxiety, PTSD, etc. – and it will come out at a later session that the patient is a victim of IPV. I don’t think their provider knows at the time they  give the referral for them to come talk to me.How do you think rates of provider screening for IPV might be improved? Just by making it a habit to follow up the routine questions about sexual health with asking about the patient’s relationships – how they’re doing, then naturally flows into if the patient has ever felt unsafe.INTERVENTION AND METHODOLOGY❖ Newtown Primary Care providers most frequently utilized HPI templates adapted from pre-existing public phrases within the EMR system to structure interviews during wellness visits❖ Intervention: Create a concise, effective IPV screening template for use within annual wellness visit HPI phrases to increase provider awareness, ease of access, and implementation❖ USPSTF recommends initial screening with a validated tool, followed by referral to intervention services, including local and national resources, if the screen is positive4❖ Evaluation of the validated screening tools identified the Woman Abuse Screening Tool – Short Form (WAST-SF) as time efficient and efficacious (sensitivity: 93%, specificity: 68%)7❖ Positive screens should be assessed for risk of immediate harm6RESULTSIPV Screening Template:Are you currently in a relationship? No/YesIn general, how would you describe your relationship? No tension/Some tension/A lot of tensionYou and your partner work out arguments with: No difficulty/Some difficulty/Great difficultyIf patient responded A lot of tension or Great difficulty, assess immediate harm risk:Has the physical violence increased over the past six months? No/YesHas your partner used a weapon or threatened you with a weapon? No/YesDo you believe your partner is capable of killing you? No/YesHave you been beaten while pregnant? No/YesIs your partner violently and constantly jealous of you? No/YesResources were not applicable/provided/deferred, including follow up with in-house Behavioral Health services, Women's Center of Greater Danbury and National Domestic Violence Hotline 1-800-799-SAFE (7233).Blue text indicates default selections from an EMR drop-down menu❖ IPV screening template (right) comprised of the WAST-SF, a 5-question immediate harm risk follow up, and resources was disseminated among the Newtown Primary Care providers❖ 3 of the 6 providers self-reported incorporating the IPV screening tool into their personalized HPI templates for annual wellness visitsEVALUATION OF EFFECTIVENESS AND LIMITATIONS❖ IPV screening template was met with positive feedback from the Newtown Primary Care office providers❖ Inclusion of the screen into providers’ HPI templates increases provider awareness at a minimum, even if the questions are not asked❖ Follow-up quantitative data needed to assess provider screening rates❖ Consistent use of the amended HPI template facilitates provider comfort with screening and normalizes screening questions at wellness visits❖ Inability to create a network-wide public phrase severely minimized ubiquity of the screening tool in WCHN❖ Currently template is only available to providers it has been personally shared with ❖ Difficulty implementing the screen if partner is present during the wellness visit❖ Time constraints limited evaluation of screening implementation and patient responseRECOMMENDATIONS FOR FUTURE INTERVENTIONS❖ Work with EMR technology services to incorporate the IPV screening tool directly into preexisting public phrases or create an independent IPV screening public phrase for network-wide provider access❖ Regularly assess provider screening rates through QA initiatives❖ Coordinate with the Women’s Center of Greater Danbury to organize staff training to reinforce provider awareness and provide tools for a conscientious approach to IPV screening  ❖ Incorporate a one-on-one portion of wellness visits in which to ask sensitive screening questions❖ Place IPV information in the office lobby, restrooms, and exam rooms to facilitate community awareness and discrete dissemination of resources❖ Gauge patient response to IPV screening via surveysREFERENCES1. Preventing Intimate Partner Violence. Centers for Disease Control and Prevention. 2019. 4/22/2019. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html2. Smith, S.G., Zhang, X., Basile, K.C., Merrick, M.T., Wang, J., Kresnow, M., Chen, J. (2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief – Updated Release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 3. Connecticut Service Statistics. Connecticut Coalition Against Domestic Violence. 2018. 4/22/2019. http://www.ctcadv.org/information-about-domestic-violence/statistics/ 4. Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478–486. 5. Peterson C, Kearns MC, McIntosh WL, Estefan LF, Nicolaidis C, McCollister KE, Gordon A, Florence C. Lifetime Economic Burden of Intimate Partner Violence Among U.S. Adults. Am J Prev Med. 2018 Oct;55(4):433-444. doi: 10.1016/j.amepre.2018.04.049. Epub 2018 Aug 22. PubMed PMID: 30166082; PubMed Central PMCID: PMC6161830.6. Dicola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94(8):646-651.7. Rabin R, Jennings J, Campbell J, Blair-Merritt M. Intimate partner violence screening tools. Am J Prev Med. 2009;36(5):439- 445

Intimate Partner Violence: Improving Screening Rates in the Primary Care Setting

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Intimate Partner Violence: Improving Screening Rates in the Primary Care Setting

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