The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center: A comprehensive, nurse-led telehealth model to address disparities in sexual assault care

Abstract

Background:

Rural and underserved communities often struggle to provide access to specialized health care, including sexual assault care. Telehealth is an effective solution for providing access to an array of specialized health care services. Prior sexual assault telehealth programs have provided evidence that telehealth is a feasible and acceptable solution. However, there is scant information about program development and considerations in the literature to guide those who may seek to implement a sexual assault telehealth program in their communities.

Purpose:

The purpose of this paper is to describe the Sexual Assault Forensic Examination Telehealth (SAFE-T) Center – a nurse-led model for providing comprehensive, high-quality sexual assault care in rural and underserved communities recently implemented at 3 hospitals in rural Pennsylvania.

Methods:

Using the program’s logic model, we present our community-engaged approach to the development and implementation phases of the SAFE-T Center.

Findings:

We first describe how academic researchers partnered with multiple stakeholders to form a statewide advisory board and articulated a vision and mission for the SAFE-T Center that meets the needs of local communities. We then describe the overall design of the model, how it was informed by this academic-community partnership, and how each element relates to anticipated outcomes. We also present our plans for program evaluation, expansion, and sustainability.

Conclusion:

This detailed description of collaborative partnership, coalition-building, program design and implementation can serve as a guide for hospitals and health systems seeking to implement telehealth programs to improve the care provided to survivors of sexual assault.

Sexual assault (SA) is a significant public health concern with nearly 1 in 3 women and 1 in 4 men experiencing some form of SA involving physical contact in their lifetime.¹ Survivors of SA require timely, skilled, compassionate, person-centered health care to address physical injuries, risk of pregnancy and sexually transmitted infections, forensic evidence collection to aid in successful prosecution of perpetrators, and to provide emotional and psychological support essential to healing from trauma.²

Sexual Assault Nurse Examiners (SANEs), or registered nurses specially trained and certified to meet the needs of victims, have emerged to provide this specialty care.^2,3 Care provided by SANEs improves physical and psychological outcomes for SA survivors and their effective collection of forensic evidence results in higher rates of successful prosecution when compared with evidence collected by non-SANE emergency room providers.^3,4

Unfortunately, SANEs are not available to many victims of sexual assault. In particular, there are numerous challenges to establishing and maintaining local forensic sexual assault expertise in underserved settings. Those working in rural or underserved settings have difficulty gaining access to quality training and mentoring required to deliver quality care and are hampered by an insufficient volume of patients to attain and retain proficiency. Evidence suggests rural communities not only have higher estimated rates of SA,⁵ but they also struggle with persistent shortages of specialist care providers and financial constraints.

When SANEs are unavailable, hospitals default to either having emergency department providers (eg, physicians, advance practice providers) without SA training conduct the examination or victims are encouraged to seek care at another facility. When a victim is turned away, they may forgo care altogether. When SA survivors receive care at hospitals without SA expertise, they are at risk of receiving inappropriate or substandard care and the forensic evidence needed for successful prosecution may be of poor quality or lost (ie, not collected). Additionally, “secondary victimization,” or the additional trauma survivors of SA may experience as a result of poor SA care, may occur.^6–8

Telehealth is being used broadly in health care to solve issues of access to specialty services where they would otherwise not exist.^9–11 Prior demonstrations have shown that utilizing telehealth to address SA care disparities is feasible and acceptable to both providers and patients.^12–15 Despite forensic SA telehealth being employed in a number of demonstrations over 20 years, there is limited information to inform others about best practices and key considerations in establishing successful programs in this vulnerable population.

Creative solutions are needed to solve the workforce shortage of health care providers trained to offer specialized forensic health care, especially in rural communities.^16,17 In this paper, we present a nurse-led, evidence-informed, practical solution aimed at increasing rural SANE expertise and presence in rural hospitals using telehealth. The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center, funded by the Department of Justice Office for Victims of Crime, aims to reduce SA health care disparities in rural communities. Using telehealth, the SAFE-T Center provides live SA exam consultations with expert SANEs, essential clinical precepting, peer review and quality assurance, and regular access to training and education. The SAFE-T Center model directly addresses the known barriers to providing high-quality SA care in rural communities. It is based, in part, on a successful demonstration in California.^13,14 Literature on developing and implementing these programs is sparse. We therefore aim to further contribute to the field of telehealth by detailing the novel community and stakeholder engagement elements of our program, as well as considerations and activities undertaken during the development and early implementation phases of our solution for addressing the SA care disparities that exist in rural Pennsylvania. The logic model that guided the SAFE-T Center’s development and implementation phases is displayed in Figure 1. The development of the logic model ensured that we were following a community-engagement framework as we considered the technical- and research-related needs of the model.

Figure 1.

SAFE-T Center Logic Model Used to Develop Comprehensive Telehealth Program to Enhance Access to Quality Sexual Assault Services in Rural Communities

SAFE-T Center Model

Development Phase

Identifying the problem: disparities in SA care.

Substantial disparities in SA care exist as a result of unequal distribution of specially trained SA care providers such as SANEs. While any interested and motivated registered nurse or other health care provider (eg, physicians or advance practice providers) may seek training in SA care, rural hospitals face barriers to providing training and clinical experience for interested providers. Beyond training, barriers to retaining a team of trained SA care providers also exist (Table 1).^16–18 Moreover, these barriers exist within a broader context of rural hospitals struggling with financial constraints and an overall shortage of health care providers.

Table 1.

Barriers to Providing High-Quality Sexual Assault Care in Rural Communities

Barrier	Consequence
Training and Clinical Mentoring	Rural examiners often required to travel long distances to attend training Training cost-prohibitive for hospitals, nurses Absence of clinical mentoring Few opportunities for continuing education Absent or limited peer review (gold standard)
Low volume of cases	Examiners do not have access to sufficient clinical experience to attain proficiency Examiners unable to hone skills needed to conduct exams while also providing trauma-informed, person-centered care
Financial constraints experienced by rural hospitals	Cost of training high given low return/ reimbursement Cost of providing on-call pay for 24/7 coverage is prohibitive High turnover and cost to replace nurses who leave the field
Few examiners	Examiners practicing in isolation without peer-review or mentorship can lead to burnout and high turnover
Turnover and burnout	Lack of experienced SANEs to provide leadership and mentoring to newly trained SANEs

Despite these barriers, financial constraints, and provider shortages, Pennsylvania legislation requires that all hospitals providing emergency services provide SA care; however, there is no oversight on the quality of SA care. Hospital provision of these services is enforced by the state’s department of health; hospitals may be cited if they fail to provide emergency SA care services. However, aside from reimbursing hospitals for SA forensic exams using funds allocated through Victims of Crime Act funds, the state does not provide the resources for hospitals to maintain SA care providers.¹⁹ In Pennsylvania, each county is required to have a rape crisis center (ie, victim advocacy) covering hospitals within each county. There is no state oversight of the communication or coordination between law enforcement (including district attorneys), victim advocacy, and SA care providers within each county. As a result, county-level sexual assault responses vary widely across the state.

Envisioning a solution.

The vision for the SAFE-T Center was developed by a team of clinicians, researchers and community partners motivated by the shared desire to address disparities in SA care. This vision was the result of a community-engaged approach that incorporated stakeholders’ knowledge of the unique problems faced by their communities as well as empirical evidence from academic research studies, including those published based on the trials/experiences of the PI. The partners also sought to envision a solution that built upon community strengths, such as the existence of hospitals with administrators and nurses passionate about improving the care delivered to this vulnerable population. As a result, the main research questions we aimed to answer during the planning, development, and early implementation phases were:

1. Can we develop an academic-community partnership involving Pennsylvania stakeholders and communities in need of improved SA care?

2. What activities must be undertaken prior to launching a comprehensive telehealth program in rural Pennsylvania hospitals?

Recognizing that rural communities face many barriers to training and sustaining a team of skilled SA providers, we hypothesized that focusing our solution on not only the known barriers to providing quality SA care, but also on the existing resources in rural partner communities, could begin to address the problem of disparities in SA care in Pennsylvania. Nurses with some SANE training in rural communities were identified as an existing resource that could be leveraged to begin to address the problem of disparate SA care.²⁰

Stakeholder engagement.

Recognizing that providing expertise and technologic support is insufficient for generating sustainable change in the field, the SAFE-T Center approach engaged community stakeholders in the design, implementation, evaluation, and adaptation of interventions in order to improve intervention adoption and increase the dissemination of results.^21,22 Further, data on SA care is necessary for evaluation yet extremely difficult to obtain,^23,24 and interventions using a community-based approach have demonstrated success in increasing the quality, relevance, and utility of information collected to help measure efficacy of interventions on otherwise difficult-to-reach populations.²⁵ With careful attention to coalition building, the SAFE-T Center developed a strategy for incorporating a community-engaged approach: develop a statewide advisory board, engage hospitals and communities, and capitalize on the ability of nurses to foster and support a partnership model to enhance the quality of SA care.

Identify and engage a statewide advisory board (SAB).

An important step in coalition building was to form an advisory board. Consistent with a community-engaged approach, the purpose of the SAB is to: 1) provide insight and guidance that is unique to each stakeholder-type; 2) foster collaborative partnerships between various stakeholders; and 3) achieve buy-in from each of the sectors involved in caring for SA victims. Thus, the overall goal of the SAB is to fully engage an interdisciplinary group of stakeholders, as research has linked program sustainability with local ownership, positive collaborative relationships, and project alignment with the needs of communities.²⁶

The inclusion of members from sectors such as the state department of health, law enforcement, sexual assault advocacy centers, health care administration, office of rural health, survivors, and university researchers ensured that we considered the diverse viewpoints and experiences of individuals working to improve SA care in communities throughout Pennsylvania (Table 2). Further, community partners’ engagement in the development process provides a deeper understanding of the problems and resources that exist in their respective communities, guidance on successful implementation strategies, and insight into relevant outcomes and processes to support dissemination of findings.

Table 2.

Statewide Advisory Board Members

Type	n
Criminal Justice System (Law Enforcement, DAs)	2
Rural Hospital Administrators	3
Advocacy	3
State Agency	5
State Legislature	1
PSU Research Investigators and Faculty Consultants	7
Partner Site Nurses and Site Champions	1
Non-governmental Organizations	2
Sexual Assault Survivor	1
Total	25

DAs = District Attorneys; PSU = Penn State University

Community partner site selection.

Successful implementation of new community-based telehealth programs focused on the delivery of services the community values and perceives is needed, high-level administrative support, and local provider desire for education and support to improve skills and quality of care.²⁷ In order to understand where need existed, we worked with the Pennsylvania Office of Rural Health to establish a site recruitment plan. We identified 61 rural hospitals, 15 of which were federally designated Critical Access Hospitals, and sent invitations to hospital leadership to respond to a survey if they were interested in being considered a program partner. The survey sought information on the average number of SA cases seen each year, number of nurses who had completed baseline SANE training, and institutional support for the SANE program. We received 28 positive responses and evaluated initial goodness of fit (criteria described below) based on the responses provided.

Preliminary site visits were initiated with 5 hospitals who reported having 10 or more SA cases/year, identified having at least 1 SANE-trained nurse, and expressed a willingness to train additional nurses. We encouraged the site CEO/CNO, nurse leader for SA care in their facility, all potential SANE team nurses, and the IT leader from the organization to participate in this visit so we could better assess motivation and readiness. Building on lessons learned from the lead author’s prior experience launching telehealth sites for pediatric and adolescent sexual abuse consultation, we created an instrument to assess readiness in 4 domains: organizational, technological, clinical, and workforce.¹³ The SAFE-T Center Director and IT Director visited the sites and independently scored each site using the instrument. The hospitals with the top 4 readiness scores were selected for participation. Selected sites reflect the elements we believe are essential for community-based telehealth partnership success: institutional support, nurses eager for mentoring and educational resources, and a stated desire to improve SA care.

Local community engagement.

Following the initial selection process, we worked with each of the 4 sites to host a SAFE-T program introduction meeting in their community. The goals of the meeting were to: 1) Introduce the SAFE-T telehealth program to key stakeholders within each community (eg, hospital administrators, SA nurse examiner team members, regional district attorneys, law enforcement, and rape crisis organizations); 2) Provide a forum for community stakeholders to share their perspective on community SA care needs and to learn and ask questions about the telehealth program; 3) Establish connections between community advocates, law enforcement, district attorneys and child welfare to assess and build multidisciplinary community coordination; and 4) Build recognition of the local hospital and nurses’ commitment to providing quality care for victims within the community.

Additionally, SAFE-T Center leadership held individual meetings with multidisciplinary partners in each community (eg, District Attorney, Advocacy, Child Welfare) to determine strengths and barriers in the community response, collaboration, and interactions with the medical team. With this approach, we sought community input on how the SAFE-T Center partnership could augment current practices rather than asking for endorsement of a program that may not fit their community context. The greatest identified community barrier to a multidisciplinary team response was that SA response occurred in silos with limited opportunity for interdisciplinary collaboration. This was evidenced by statements suggesting the first time they engaged with other disciplines working with victims of assault was at the kickoff meeting for the SAFE-T partnership.

Building a team of expert SANEs.

TeleSANEs are central to the program as they serve as expert mentors to rural SANE-trained nurses in the SAFE-T Center’s model. As such, it was imperative that those recruited to the role for SAFE-T not only had substantial experience and expertise as a practicing SANE, but that they also were driven to mentor and support less experienced nurses in the field.

The SAFE-T Center Director collaborated with the Pennsylvania chapter of the International Association of Forensic Nursing (IAFN) and the Pennsylvania Coalition Against Rape (PCAR) to identify the most experienced SANEs engaged in the SA care community. Through these networks, we were able to identify SANEs whose primary role was as a forensic nurse, who understood issues faced by nurses practicing in isolation in underserved communities, and who had steadily worked to overcome those barriers in their own practices. Those identified were invited to come to the SAFE-T Center to learn about the program, about the role of a TeleSANE, and to elicit interest in joining the team. Through this process, SANEs with substantial leadership and field experience were identified and invited to apply for either key full-time coordinator positions or to be part of the SAFE-T Center TeleSANE team.

Program design.

Based on the identified problem, shared vision, and input from communities and stakeholders, the resulting program design is a comprehensive hub of SA expertise and support that aims to increase access to quality SA care and reduce the disparities that exist in rural and underserved areas. The program’s core design elements include: 1) an expert TeleSANE response team; 2) education and training programs for SA care providers in rural communities (eg, registered nurses); 3) SANE peer-review and support network; and 4) cost-effective, secure, sustainable telehealth systems with reliable IT infrastructure and support. The program’s current grant funding covers the costs of equipment, TeleSANE compensation, and education and training. Hospitals compensate their nurses at their usual rate and are not required to pay for the SAFE-T Center during this demonstration project.

Delivery of expert mentoring and quality assurance via telehealth technology.

The vision for the consultant team was to create a virtual teleforensic service in which expert TeleSANEs can securely, reliably, and seamlessly provide consultation from a private area in their home or worksite. Developing technology to enable a virtual teleforensic team allows experts to be culled from any area of the country (nurses obtain a Pennsylvania nursing license) to participate in a call rotation for telehealth consultations. This model, versus a hospital-based physical telehealth hub, affords substantial advantages in promoting work flexibility for TeleSANEs and decreased risk of instability that can occur with shifts in institutional administrative support.

Assembling an elite TeleSANE team.

A thorough process of identifying and evaluating the expertise of potential TeleSANEs was undertaken. Minimum job requirements for SAFE-T Center TeleSANEs included: IAFN SANE-A (adult and adolescent) certified, conducts at least 30 exams per year, and a minimum of 3 years of experience in the field with primary role as a forensic examiner. These requirements were enacted to ensure that TeleSANEs had substantial expertise conducting SA forensic exams and could provide needed expertise and support to less experienced rural site nurses.

The newly hired TeleSANEs were brought to the SAFE-T Center for a 2-day training. This training covered multiple aspects of the program, as well as technical aspects of the consultations including how to prepare and conduct a telehealth consultation, how to apply motivational interviewing techniques during a forensic examination, privacy and security issues, and mock consultations. Additionally—and consistent with a community-engaged approach—the TeleSANEs were asked to provide input on the overall model of care, including their role.

Technology development.

During the planning phase, the SAFE-T Center information technology (IT) team reviewed currently available technology and innovation opportunities. The Director and IT team developed a strategic vision for secure, reliable, and easy-to-use technology that was also fiscally responsible to support sustainable and scalable systems. This required a number of complex and connected efforts including: 1) Evaluating current technology and identifying opportunities for innovation; 2) Working with the University’s security analysts to ensure maximum security standards were implemented; and 3) Maintaining a focus on ease of use by the local site by ensuring systems were wireless and remotely managed through Penn State, alleviating any burden on local hospital IT. The team focused on iterative business process evaluation and improvements, technology audits, technical support implementation, and consistent monitoring. TeleSANEs practice remotely by utilizing a Penn State issued laptop; commercially available webcam; and secure, encrypted HIPAA-compliant networking solutions that have met the rigorous security standards of Penn State’s information security and compliance office.

Model of care.

Importantly, the clinical model for delivery of SA telehealth consultation is one of nurse-led “quality assurance” as opposed to “direct patient care.” In this model of care, the partner hospital SANE provides direct patient care and is considered the “trained clinician” as they have undergone basic SANE training and education to qualify them as such. SAFE-T Center TeleSANEs provide quality assurance, peer review, and expert support to less-experienced partner nurses in real time during the examination. Additionally, TeleSANEs conduct a post-consultation quality assurance review to determine whether core components of the exam were completed (eg, history, documentation). This model of care was successfully used in the prior telehealth sexual abuse program and was supported by legal counsel as well as remote law enforcement and district attorney offices.¹³ The “quality assurance” approach underpinning of this model of care has the advantage of promoting local expertise within the community and ensures that local nurses are appropriately responsible and qualified to serve as expert witnesses in courtroom proceedings within their community.

Pre-Implementation Activities

Local partner site preparation.

Following the initial community meeting, work began on critical activities to be accomplished prior to launching telehealth. Site administrators managed the execution of the memoranda of understanding with the SAFE-T Center, ensured that nurses selected to function on the team received 40-hour SANE training, implemented a formal paid call structure and schedule, and identified a site champion (a nurse in the organization to provide leadership for the local SANE response team and to take ownership over implementing the program in partnership with our team). Site champions worked closely with the SAFE-T Center’s Clinical Nurse Coordinator to gain an understanding of current protocols, practice, and community engagement efforts. Together, they assessed program needs, set goals, and worked toward desired outcomes.

Honoring and communicating local expertise.

We hypothesized that a long-term, positive impact on SANE shortages involves more than providing live telehealth support. Our model therefore provides ongoing support to rural nurses with SA training in order to empower them to develop SA expertise within their own community.

To promote community awareness of local expertise, we coordinated 2 community-focused events prior to launch of the partnership. The first event introduced the SAFE-T Center to the community, recognized community strengths, identified leaders to champion local efforts, and assessed what the community determined were gaps in SA services. The second event was a community celebration as we launched the live telehealth consultations. The goals of this event were to enhance community pride in the investment of the local trained nurses and hospital in partnering with SAFE-T to enhance quality SA care and to message the community that trained providers are ready to care for victims should they come forward. To maximize the impact of these events, we asked partner hospitals to include members of the community who care about this issue including traditional partners as well as civic leaders, media, philanthropic groups, and local educational institutions.

Training.

In the months leading up to program launch, SAFE-T Center coordinators work with identified site champions to gain an understanding of what is working well and what the site champion identifies as program or educational gaps or needs. Site champions complete a survey with information on current team structure, practices, and experience levels. The SAFE-T Center team spends a half day at the site with the local nurse team to gain understanding of established practices and procedures. Utilizing a mannequin and available site resources, the local team talks through their typical approach in working with an SA victim followed by joint discussion of differing approaches and national standards. This provides an opportunity for shared learning of best practices/evidence-based care and shared decision-making about how SAFE-T Center program elements can support and enhance, as opposed to replace or control, current practice.

Following this visit, the SAFE-T Center nurse coordinator and the site champion have phone or teleconference meetings twice a month to steadily advance the local team’s preparation for launching the partnership. Finally, at launch time, the SAFE-T team spends 2 days at the local site, orienting the local nurse team to the telehealth equipment through case-based learning and telehealth simulations.

Pilot Testing and Program Evaluation

Pilot Testing

The program, which received funding specifically for planning and pilot testing phases, has been launched and is functional in partner settings. As a result, we are currently in the data collection phase and will soon be able to publish outcomes related to the implementation, acceptability, and impact of the program in subsequent manuscripts.

Evaluation Framework

In order to increase capacity for expansion and long-term sustainability, we follow a Continuous Quality Improvement (CQI) framework.²⁸ CQI embraces the concept that system and process improvements must continually be identified and enacted to produce enhanced services and achieve outcomes. CQI examines the structure (ie, people, technology, physical assets, and financial assets of a project) in combination with the process (eg, activities, workflow, and tasks) carried out to achieve outcomes.²⁸ Utilizing a CQI process allows the SAFE-T Center to demonstrate meaningful outcomes to key organizations (eg, hospitals and governmental agencies) and will contribute to long-term sustainability of the programs.

Evaluation

Imperative to the long-term success of the program is our ability to demonstrate impact on outcomes of interest to the local community. Through community and partner engagement, we identified 4 main evaluation domains: 1) Satisfaction and acceptability of the program; 2) Quality of care and health service utilization; 3) Workforce sustainability; and 4) Law enforcement and judicial considerations. To this end, evaluation tools and considerations were developed during the Development Phase so they could be shared and refined with key partners and seamlessly integrated as needed throughout all program phases (Table 3).

Table 3.

Select Evaluation Measures and Time Points of Measurement for Implementation of the SAFE-T Center program

Measure	Participant Type	Time Point(s)	Sample Questions
Satisfaction and Acceptability of Program
Nurse Satisfaction with Telehealth Consultation	LSN, TeleSANE	After each consultation	Overall technology experience Reliability of technology How well supported did you feel? How important was access to a telehealth consultation? How much did telehealth improve the quality of the examination?
Patient Telehealth Satisfaction	Patient	After each consultation	Rate the care you received today. Having a telehealth consultation improved the care I received today. The examination helped me to feel better
# Telehealth consultations declined by patients	Hospital	Continuously	n/a
Qualitative Interviews	Multiple Stakeholders with direct involvement (LSNs, TeleSANEs, advocates, hospital administrators, law enforcement)	6 months after program implementation and annually thereafter	Describe how the SAFE-T Center meets (or does not meet) the needs of your hospital? Describe how partnering with the SAFE-T Center facilitated changes to the way forensic care is delivered in your hospital?
# Technology failures	SAFE-T	Continuously	n/a
Quality of Care and Health Service Utilization
Policies/Procedures representing best practices in place	Hospital	Continuously	Examples include presence of: 24/7 SANE coverage SANE-led exams Automatic calls to advocate
Exam quality and completion	Expert SANE reviewer	During and after each consultation	Quality Improvement checklists Interaction, Examination technique, Image quality, Evidence collection, Documentation
Subsequent use of support services	Patient	Annually	Surveys and questionnaires for patients and advocacy centers
Workforce Sustainability
Supportive/beneficial policies in place	Hospital	Continuously	Examples include presence of: Paid on-call Protected time for meetings/continuing education
LSN Recruitment/Turnover	Hospital	Continuously	n/a
TeleSANE Recruitment/Turnover	SAFE-T Center	Continuously	n/a
LSN Confidence	LSN	Annually	Confidence in: Ability to provide compassionate support Ability perform a complete forensic exam - Ability to capture quality images
Law Enforcement and Judicial Considerations
Nurse involvement in sexual assault response teams (SARTs) and expert witness testimony	LSN	Continuously
Investigative case trajectory tracking	Law Enforcement (Investigators, District Attorneys)	Annually

LSN = local site nurse (nurses providing SA care during telehealth consultations in rural hospitals)

Discussion

Ongoing and unsolved shortages in the availability of trained forensic health care providers for SA (eg, SANEs) has prompted a need for novel solutions to address the resulting disparities in care, especially in rural communities. Telehealth has proven to be an effective tool to bring health care expertise to communities where it would otherwise not exist.^9–11 Interest and investment in the use of telehealth technology to bridge gaps in training, mentoring, and provision of quality SA forensic health care has grown substantially in the past decade.^29–31 Yet, published information on program development models, considerations, acceptability, and effectiveness is sparse. This manuscript provides detail on the SAFE-T Center development model. Information on acceptability and effectiveness of the program will follow as phase 1 and 2 are completed.

Kellogg and colleagues published one of the earliest descriptions of the use of telemedicine in child sexual abuse examinations.¹⁵ They described the experiences of 7 states that had implemented a “store and forward” model of case sharing and peer review after consultation completion. The purpose of the article was to describe the benefits and challenges of delivering specialty consultation for child sexual abuse examinations using technology. However, there was no description of the program or approach to the telemedicine programs put in place. Common challenges cited in these early demonstrations were related to funding, consistent technology support, adequate clinical skill of the remote provider, and lack of network infrastructure.¹⁵ As opposed to a “store and forward” telemedicine model, Foster and Whitworth implemented a live examination telemedicine program in Florida and published a brief overview of the state implementation model.³² Their work focused on the perspectives of providers on both sides of the transmission rather than the process for developing and implementing the program. They found that not only was the consultation experience acceptable but also that local nurses took great pride in being part of the solution to an important problem within their community.³²

The demonstration of a pediatric telehealth program to support delivery of expertise and training to rural communities, published by the first author and colleagues at the University of California Davis, offered a description of the initial training of the local providers, the equipment used, and an overview of the service and interactions between the consultant and local providers.¹³ This demonstration, in existence for over 10 years, showed that telehealth was feasible; acceptable to practitioners, patients, and families; and resulted in improved quality of care. Missing from the resulting publications that highlighted the quality of care outcomes was a description of the entire model, inclusive of approach to community partnership, detailed implementation, and lessons learned at each stage. As interest in developing telehealth programs for SA grows and requests for information about how best to do so intensify, this paper aimed to fill this gap by sharing the model that resulted from over a decade of experience in rural partnerships.

Finally, the National TeleNursing Center recently published the foundations of their telehealth quality-caring model.¹² This model highlights that quality can be fostered through caring relationships established with the patient and family, others, self, and the community. There are numerous similarities between the SAFE-T Center model’s approach and the approach described in the National TeleNursing Center model, including engagement of multidisciplinary community partners at the point of care as well as during community partnership meetings. Our paper builds on this work by specifically focusing on early aspects of model development including site selection, engagement of key stakeholders, and program design that are anchored to evaluation outcomes.

While progress has been made since earlier demonstrations of sexual abuse telehealth programs, descriptions of models for successful implementation, adoption, and evaluation remain scarce. Telehealth holds great promise as a tool to deliver expertise where it is needed for forensic SA examinations. For this delivery model to be broadly and successfully scaled, detailed descriptions of telehealth programs are needed so that others can adopt successful approaches and adjust based on previous lessons learned. A novel feature of this telehealth model is that it is nurse-led and focuses on enhancing nursing care already being provided at rural hospitals. We believe the focus on nurses makes the model more easily applied in rural or underserved hospitals where nurses are already leading this response. This model does, however, require financial investment for equipment and TeleSANE compensation. The SAFE-T Center is therefore actively exploring cost-sharing models as a means of sustaining the program after the grant period.

This logic model paper fills a substantial gap in the literature by describing in detail the theory-driven approach the SAFE-T Center model has used to build a hub and spoke telehealth solution to provide training, mentoring, and real-time peer review in order to increase access to quality SA care in underserved communities. A major goal of this model is to situate knowledge from lessons learned from a successful demonstration of child and adolescent sexual abuse telehealth in rural California communities within a community-engaged framework that can better address issues of acceptability, feasibility, and sustainability. Further, the continuous quality improvement and focus on meaningful, measurable outcomes will provide stakeholders with evidence of the impact of such a model.

A critical component of our model is a comprehensive evaluation of the effectiveness of each stage of the model from multiple stakeholders’ perspectives. Using the program’s logic model as a guide, we have been collecting these data since the inception of the project and those efforts are ongoing. Given the various stakeholders and types of outcomes (eg, implementation, telehealth intervention, and individual outcomes) we are deploying a comprehensive, systematic, multi-component evaluation to capture the SAFE-T Center’s overall impact and disseminate findings to inform policy and future efforts. As such, the evaluation will consist of both qualitative and quantitative data. Evaluation tools were developed and tailored to the SAFE-T Center as no standard evaluation tools for SA care telehealth interventions exist.

A limitation of this current paper is that it solely provides the foundations of the model and approach. Planned evaluation of this model will help others understand aspects that are successful and those that require course correction to meet desired outcomes. Timely dissemination of findings at various stages will contribute to knowledge of best practices for building and growing SA telehealth services that solve access to expertise and improve care for those who have experienced sexual violence, wherever they live.