Abstract
Background:
More than 320,000 US adults are sexually assaulted yearly. Sexual assault nurse examiners provide trauma care and perform forensic medical examinations and evidence collection. Medical follow-up after sexual assault plays a significant role in the physical, mental, and emotional healing process. Essential care provided at a primary care follow-up after the initial forensic medical examination includes injury and medication follow-up, sexually transmitted infections testing, and referrals for counseling and/or advocacy. Historically, the reported follow-up rates after a medical forensic examination for sexual assault are low (31%-35%). Patients who suffer sexual assault often experience a disparity in follow-up healthcare and treatment of related and subsequent medical and psychiatric conditions.
Methods:
The study period was May 1, 2016 through October 31, 2016. Coordination of follow-up care was offered to all patients ≥18 years who underwent a forensic medical examination and evidence collection kit for sexual assault. A sexual assault nurse examiner or social worker scheduled follow-up appointments for patients who agreed. Patients with appointments were mailed letters verifying dates, times, and physician locations. Letters including patient information, suggested follow-up testing, and patient needs were mailed to the physicians. Appointment compliance was verified via patient self-report and chart review.
Results:
Sixty patients were included in the study. Of them, 38 (63%) were covered by Medicaid and 16 (27%) were uninsured. Of the 60 patients in the study, 34 (57%) agreed to schedule follow-up appointments. Twenty of those 34 patients (59%) saw their physician for follow-up. Of the 26 patients (43%) for whom appointments were not scheduled, 24 (92%) declined follow-up calls and an appointment, and 2 (8%) were homeless without the ability to receive calls or to get to an appointment. The follow-up for patients who agreed to be contacted and to schedule appointments was higher than historic reports (59% vs 31%-35%), but the follow-up rate for the entire study population remained consistent with previously published data at 30%. Communication and transportation were identified as barriers to follow-up.
Conclusion: Patients who agreed to follow up and scheduled their own appointments had the highest follow-up rates. Further study needs to identify why patients refuse follow-up appointments or calls, but these data will be difficult to obtain because of the nature of the study population presenting after an acute sexual assault. Resources to assist patients with communication and transportation needs may improve follow-up.
PROJECT MANAGEMENT PLAN – Improving Primary Care Follow-Up After Sexual Assault.
| Vision Statement | Our vision is to decrease healthcare disparities associated with poor medical follow-up after sexual assault by implementing a multidisciplinary plan to improve primary care follow-up for patients cared for in our Sexual Assault Nurse Examiner Program. |
| Team Objectives | Our objective was to develop an intervention plan that would bridge the communication gap between acute and follow-up care and provide a caregiver education curriculum. Our project assumption was to involve a small sample size because of the expected loss to follow-up. Stakeholders included patients (improved care), caregivers (education), and the community (support mechanism for this patient population). Our measures of success were a 25% increase over reported national average 2-week follow-up rates in this population, tracked ordering and completion of laboratory testing prior to 2-week follow-up visit, and 100% scheduling of 2-week follow-up visits. |
| Success Factors | We improved follow-up rates by 25% compared to what has been historically reported (31%–35%). |
| Barriers | The largest barrier we faced was the inability to communicate with patients after the initial encounter because many patients refused follow-up communication and some patients were homeless without communication means. The next largest barrier was lack of transportation for the follow-up appointments. Finally, we were not able to access the health records for all of the patients because some of them received follow-up care outside our health system. |
| Lessons Learned | The single most important piece of advice to provide another team embarking on a similar initiative is to be prepared for unanticipated results. We were surprised by the number of people who were homeless, without any means of communication, and/or without transportation. This made us more aware of the fundamental lack of resources in our study population. |