Screening and Intervention for Intimate Partner Violence in Healthcare Settings: Creating Sustainable System-Level Programs

Abstract

Among the barriers to routine screening for intimate partner violence (IPV) are time constraints, a lack of protocols and policies, and departmental philosophies of care that may conflict with IPV screening recommendations. To address these barriers, systems-level interventions are needed; in this article, we describe one model that may overcome these obstacles. We discuss how this systemic approach may best be implemented in both out-patient clinics and emergency departments (EDs) and note that evidence for its success will be required.

Introduction

Intimate partner violence (IPV) is a serious public problem that nationally affects between 2.7% and 13.9% of women and 2.0% and 18.1% of men each year.¹ Within healthcare settings, the reported prevalence of IPV survivors in primary care and emergency departments (EDs) ranges from 12% to 45%, depending on how IPV is defined and measured.^2,3

IPV survivors experience a wide range of injuries, including eye, face, head, and neck injuries⁴; traumatic brain injury; and lifelong disability.⁵ Compared to nonbattered women, IPV survivors experience lower overall quality of health,⁶ impacting virtually every organ system.⁷ IPV survivors exhibit higher rates and levels of depression, which may persist as long as 5 years after the violence has ended.⁸ IPV survivors also exhibit elevated rates of anxiety and posttraumatic stress disorder,⁹ as well as problems with alcohol and other substance abuse.¹⁰ IPV survivors exhibit more suicidal ideation and attempts.^11,12 Finally, IPV-related homicides of women in the United States each year number around 1,200.¹³

A number of studies have found that IPV-involved patients use more healthcare resources on an annual basis than do patients without this risk factor.^14,15 Further, the higher use of healthcare resources by abuse survivors does not end when IPV ends. Rivera et al.¹⁴ observed that increased out-patient visits by abuse survivors continued for up to 16 years after the abuse ended.

Primary- and emergency-care settings are important settings in which to identify and help IPV survivors.^16,17 Ideally, the healthcare setting could provide opportunities for private communication with a healthcare provider and be equipped to manage crises and provide comfort measures, such as emotional support, information, and guidance, along with being able to make connections to community-based social service agencies. The IPV screening and counseling for all adolescent and adult women recommended by the Institute of Medicine (IOM)¹⁸ and the U.S. Preventive Services Task Force¹⁹ as part of preventive care, along with the Department of Health and Human Services,²⁰ have adopted these recommendations as part of preventive care offered through the Affordable Care Act. Unfortunately, the promise of healthcare settings for identifying and helping abuse survivors is to date as yet unfulfilled.

Early research on IPV identification showed that fewer than 2% of women were asked about IPV by a doctor or a nurse in family practice settings²¹; in emergency settings, only about one-tenth of abuse victims were identified.²² The Joint Commission on Hospital Accreditation²³ has published performance criteria for hospitals to educate staff, identify abuse victims, maintain community resource information, and assist with referrals in an effort to increase screening and identification. More recent research suggests that the amount of screening and identification is a little higher than that reported in early research, but the numbers continue to reflect deficiency in asking women patients about IPV in clinical settings.^16,24,25 Importantly, screening does not necessarily result in identification or interventions.

Kothari and Rhodes²⁶ tracked 964 police-identified women victims of IPV through all eight EDs in one county and found that 864 received care in at least one ED in the year of the index assault. Over a 3-year study period, 82% of victims generated a total of 4,456 ED visits. IPV screening was documented in 30% of the 4,456 visits but resulted in only 6% positive screens. However, because IPV victims had high utilization of ED services, 23% of individual IPV victims were eventually identified. An in-depth study of the visits that resulted in IPV identification found that less than 25% of identified victims were even referred to IPV services,²⁷ which calls into question the effectiveness of IPV screening in acute healthcare settings. Despite many barriers to following through on a referral independent of screening, a recent systematic review found no evidence that screening leads to significantly more referrals to advocacy-support resources.²⁸

Is Screening Effective for Helping IPV Survivors?

In general, randomized, controlled trials of IPV screening have provided little evidence supportive of the benefit of IPV screening for reducing IPV.^29,30 There is some evidence that screening results in differential rates of identification of victims across types of medical clinics, with higher identification in obstetrical clinics and lower identification rates in EDs.²⁸

Many of these studies, however,^29,30 focused on screening only, and safety protocols for the studies employed IPV interventions for control participants as well as experimental participants. This probably resulted in comparable intervention for both screened and unscreened groups and may have masked any benefit of screening. Moreover, research on the impact of screening, without any intervention or long-term follow-up, reflects an approach to medicine that emphasizes attention to the acute problem only, without appreciation of the deeper context of the problem of IPV in a patient's life.

More recent formulations have begun to suggest that effective healthcare-based IPV interventions should focus on IPV using a chronic-care model.^31,32 This would involve incorporating IPV screening within broader systems-level changes.^16,32–34

Research has shown that by making changes at the system level, dramatic increases in IPV screening can be realized when these changes are paired with the presence of in-house IPV-victim advocates.^34–38 Comprehensive reviews have also demonstrated the importance of system-level change and support to facilitate IPV screening and intervention.^37,38 This suggests that in order to reach the goal of the IOM, both screening and high-quality long-term IPV services will need to be paired at the point of care. Doing so will require sustainable changes in systems of care.

In that regard, a number of systemic barriers to IPV screening and intervention have been identified, including time constraints,^39–41 lack of protocol and policies and procedures for screening,^27,37 departmental or unit philosophies of care that may contradict IPV screening recommendations,⁴⁰ and “attitudes and perceptions” that reflect a less than optimal attitude toward screening.^40,41 System-level interventions will need to address such barriers. In this article, we describe a model for overcoming system-level barriers and implementing a sustainable response to IPV.

Creating Sustainable Systems Change

Ambuel et al.^16,42 have provided a six-point model for creating sustainable system change to improve IPV screening and intervention in the clinic or ED setting. First, and key to the model, is the development of internal, on-site IPV expertise. Research has shown that quick access to an IPV advocate increases the likelihood of identification and referral for services.³³ Selected clinic staff members are trained to function as IPV advocates. Health-based advocates receive over 20 hours of training on definitions and dynamics of IPV; healthcare prevalence statistics; the health impact of IPV; knowledge of and collaboration with local advocacy programs; legal and ethical issues in working with IPV survivors; skills training for asking about and responding to reports of IPV from patients, including assessing danger; and helping to develop safety plans. Key to training is collaboration with local advocacy programs for development and delivery, with emphasis on IPV as a health issue.⁴² These specially trained in-clinic advocates play a key role in maintaining and advancing the clinic or system's initiatives to address IPV. The advocates take the lead in developing policies and procedures, provide or direct staff and provider in-service training, develop patient-education resources, and lead continuous quality-improvement projects. Advocates also accept immediate referral of survivors who need more time and attention than the physician or nurse can provide. Advocates possess the expertise to assess danger, provide emotional support, develop safety plans, and facilitate referrals to local advocacy programs. Studies are beginning to demonstrate that having an IPV advocate on site for quick referral increases screening, identification, and referral.^16,33,36 EDs, which provide round-the-clock patient care, will require the identification and training of several advocates.

A second key to the model is saturation training, or the training of all staff members working within a particular clinic or unit. This aspect increases staff awareness about how IPV affects health and increases sensitivity to the needs of patients in crisis. Saturation training also results in identification of job-specific roles for various staff members who may encounter IPV. For example, reception staff may develop communication pathways for notifying a nurse of IPV witnessed in the waiting room.⁴³ Saturation training also communicates an important message that the organization supports efforts to address IPV and that the issue belongs to the entire system, not just front-line providers. Such advocate training and clinic saturation training provides a common knowledge base and enhances communication to help survivors as part of a team effort.

The third key to the systems-change model is the development of clinic or unit-based policies and procedures, which are critical to a successful systems-based response to IPV.³⁷ Policies and procedures legitimize and make concrete the organization's commitment to address the issue. However, because each setting is different in its orientation to patient care, policies and procedures should reflect such uniqueness.⁴²

The fourth key to a sustainable systems-change model is collaboration with local advocacy agencies and IPV experts. For example, a health system can work with advocacy groups to increase familiarity with community resources, thus creating the opportunity to make more effective, “warm” referrals. Advocacy programs can be invited to support ongoing in-service efforts and can function as consultants to support the in-clinic advocates or the broader system initiative.

A sustainable systems-level intervention also incorporates continuous quality-improvement strategies.⁴⁴ Minsky-Kelly et al.⁴⁵ describe an approach that included chart audit, along with aggregate feedback to department managers, departmental in-service interventions, and subsequent reaudits. This strategy demonstrated vast improvements in IPV screening within departments over time.

Finally, the systems model advocated by Ambuel et al.¹⁶ includes primary prevention as an important element. Primary prevention efforts within a healthcare system can include posted signage and pamphlets that can be given out to patients. Ambuel et al.⁴² describe providing information on healthy relationships and healthy conflict-resolution strategies to all patients who screen negative for IPV. Including healthy-relationship information, as well as helping resources for persons at risk, is another way to support primary prevention efforts.

Implementing Systems Change

Implementing systems change is a process that occurs over time. Initial implementation strategies include meeting with key system decision makers and securing buy-in.^16,38 This may include providing education on the health impact of IPV, as well as potential costs in terms of time and human resources to both implement and maintain IPV screening and intervention. A second step involves convening a systemwide IPV task force to plan clinic or department-wide implementation. The task force provides staff-level involvement and buy-in, particularly as individual members take on necessary tasks, such as researching clinic policies and procedures or collecting community resource information, and planning clinic or department-wide educational initiatives. Third, candidates for advocate positions are identified and given intensive training. Then they partner with key community and local experts to develop and deliver saturation training. Following saturation training will be development of continuous quality- improvement projects to assess what is working well and what changes need to be made. Doing so also involves regular communication with key stakeholders to both exchange feedback and make necessary changes.

Evaluation

Unfortunately, there is scant literature that supports system-change efforts to screen and help victims of IPV. Studies in this area have shown that systems-level interventions can increase rates of provider screening⁴⁶ and IPV identification in healthcare settings^16,32,33 and rates of referral of identified abuse survivors to local advocacy programs.³³ Only one high-quality study finds that interventions provided as part of ongoing clinical care actually decrease subsequent violence and improve outcomes for abused women.⁴⁷ The most compelling evidence comes from the National Institutes of Health (NIH)-DC Initiative to Reduce Infant Mortality in Minority Populations in Washington, DC. The randomized controlled trial assessed an integrated screening and counseling intervention compared to usual care in an urban perinatal population. Pregnant women were randomly assigned to receive perinatal counseling by IPV-trained social workers. Counseling for IPV also addressed comorbid health risks, such as smoking and depression; emphasized danger assessment, safety behaviors, and empowerment; and provided information on community resources. The study had a remarkably high retention rate (91%) and demonstrated significantly fewer recurrent episodes of IPV during pregnancy and postpartum periods (adjusted odds ratio [OR], 0.48; 95% confidence interval [CI]: 0.29–0.80). Women in the intervention group also had better birth outcomes, including fewer preterm neonates, lower rates of very low birthweight neonates, and significantly increased mean gestational age (38.2 vs. 36.9 weeks for the control group). Moreover, depression, smoking, and environmental-smoke exposure decreased in the intervention group.

The authors hypothesized that the integrated nature of the intervention as part of routine clinical care contributed to its success.^47,48 Knowledge that routine screening in conjunction with ongoing social work counseling is effective at reducing prenatal IPV and comorbid adverse health behaviors and is associated with improved pregnancy and birth outcomes finally tipped the weight of the evidence toward routine IPV screening—at least among young urban perinatal women engaged in a close ongoing relationship with a medical home that has high-quality IPV-trained social work resources. More work is needed before we can make evidence-based recommendations for routine IPV screening of women in all healthcare settings.

Future Directions

Although systems-change strategies appear to offer considerable potential to facilitate healthcare-based IPV screening and intervention, research supporting systems-change intervention is lacking. One of the impediments to such research has been the ability of health systems to ensure routine screening. However, with the increase of electronic and personal health records, computer-based screening can be done during patient waiting time in the ED or online before a primary-care visit. Since computer screening for IPV in the context of asking about other health-related social issues has been found to be safe,^30,49 there is no reason not to routinely screen all patients as part of their intake form or annual physical. The National Cancer Institute has defined a short set of validated psychosocial screening surveys that it recommends be included in electronic health records (EHRs). This set needs to be expanded to include questions about IPV.⁵⁰ Moreover, the integration of psychosocial screening as part of the work flow using computer-based EHRs can be done at the marginal cost of providing a private space and ensuring confidentiality of the screening form. It is also feasible to offer online educational materials and personalized referrals to local resources. Use of technology has the potential to increase the confidentiality of the IPV screening process and allow health systems to ensure that all patients can get referrals, regardless of whether they choose to share their screening results with their provider. There is also the possibility of developing and testing computer-based IPV counseling interventions, using tailored messaging. Similar violence-intervention projects have been tested with adolescents and been found to be effective.^51,52

However, there will remain a number of issues to resolve to ensure that no one willing to disclose IPV to a healthcare provider falls between the cracks. System-level research designs will need to also track harms as well as the benefits and thoughtfully identify the most appropriate outcome variables for this area of study. Violence reduction is the ideal outcome. However, the issue is complex and not one that is necessarily under the control of either the health provider or the IPV-involved patient. As pointed out by Hamberger et al.⁵³ and others,^28,38,54 it may be necessary to identify and study other outcomes, including safety, and patients' feelings of support from their healthcare provider. In addition, other indices of success will need to be identified. For example, implementation of system-level changes was found to be cost effective.⁵⁵ Furthermore, O'Campo et al.³⁸ found in their systematic review that system-level interventions that included strong institutional support were more likely to be successful (defined as screening, IPV disclosure, and identification rate) than noncomprehensive, “screening-only” programs.

Zink et al.³² point out that a chronic or planned-care model of IPV screening allows outcomes to be measured at both the individual and health system levels. It will also be valuable to investigate the impact of proactive outreach and use of community health workers with patients experiencing abuse using the framework of disease management.^32,44,56,57

One goal of the Affordable Care Act (ACA) is to not only reduce costs but also improve the quality and value of healthcare.⁵⁸ It is well established that IPV increases healthcare utilization and costs and has long-term adverse physical and mental health consequences. Many primary-care practices and community health centers are trying to transition into primary-care medical homes with the goal of taking a broader view of health and working as teams of providers to integrate behavioral health into routine care.⁵⁶ These delivery-system changes are responding to new incentives that are designed to favor patient-preferred health outcomes.⁵⁹ It will be important to continue to conduct comparative effectiveness research that includes patient-centered outcomes, as well as system-level outcomes, as we try to operationalize IPV identification and interventions and align health system incentives to both reduce costs and improve the quality of care.

In conclusion, the evidence in support of system-level interventions for IPV screening and interventions in healthcare settings is compelling but remains inconclusive. More work is needed to identify whether the dramatic changes that are occurring in the delivery of both acute and chronic healthcare, such as the widespread use of health information technology, delivery-system redesign, and behavioral health integration, can be leveraged to create the sustainable infrastructure needed to support integrated IPV screening and interventions.

Acknowledgments

This article is based on presentations by the authors at the HHS-sponsored Intimate Partner Violence Screening and Counseling Research Symposium, December 9, 2013, Rockville, MD.

Author Disclosure Statement

No competing financial interests exist.