1. Marie Kenny, MA
CT Coalition Against Domestic Violence
October 25, 2013

2. Financial Disclosure
There is a financial relationship
between CCADV and CHC, Inc.
CCADV provides some funding to
New Horizons,
a CCADV member program
within CHC, Inc.
2

3. AGENDA
 Defining Domestic Violence
 Prevalence
 Dynamics
 Screening Patients
 Why?


Benefits for Patients
Benefits for Providers
 How?


Enhancing Safety
Building Confidence
 Following Up with Patients
3

4. Defining Domestic Violence
Why Routine Screening?
 1 in 4 women experiences domestic violence in her
lifetime1
 40% of female adolescent patients seen at urban
clinics had experienced IPV2
 21% reported sexual victimization2
 More than half (53%) of women seen at family
planning clinics reported physical or sexual IPV3
 $4.1 billion is spent annually for direct medical and
mental health services related to IPV4
4

5. Defining Domestic Violence
CCDAV Programs Provided (FY 13)
 Crisis intervention services to 25,130 individuals
 Calls to statewide and individual agency hotlines
 Safe Home Services to 2,069 victims
 1,220 adults and 849 children received emergency shelter
 Community Services to 13,949 victims
 Individual counseling, safety planning, support groups, legal
advocacy and information & referrals
 Criminal Court-based services to 39,585 victims
 Safety planning, counseling, court advocacy, assistance with orders of
protection, information & referrals
www.ctcadv.org
5

6. Defining Domestic Violence
 DV goes by a variety of names
 IPV, abuse, battering, dating violence
 Certain elements are universal
 a PATTERN
 of BEHAVIORS
 to establish and maintain CONTROL
 over an INTIMATE PARTNER
6

7. Defining Domestic Violence
BEHAVIORS
 Psychological
Denial and minimization of abuse, monitoring, jealousy, social isolation, “Jekyll and Hyde”
public vs. private persona

Financial
Sabotage of school or work, denying access to accounts, car or phone, making unilateral
spending decisions, making threats about public assistance, destroying credit, shutting off
utilities, etc.
 Emotional
Degrading, humiliating, condescending, threatening, guilt-tripping, using kids
 Sexual
Coercive sex, rape, threatening to “out” a partner, cheating, reproductive coercion
 Physical
Does NOT always leave a mark, can be infrequent, throwing or breaking
things, intimidation tactics can be very subtle to others
7

8. Defining Domestic Violence
DEMOGRAPHICS
 Typically male on female BUT not always
 Some men are victims of women
 Similar rates for same sex relationships5
 MOST men do not abuse their partners
 Prevalence cuts across all demographics
 Impacts all
racial, ethnic, economic, religious, educational, professio
nal backgrounds, any age and sexual orientation
 Look at behaviors not demographics
8

9. Screening Patients – Why?
The U.S. Preventive Services Task Force (USPSTF)6
recommends that clinicians screen women of
childbearing age for IPV and provide or refer women
with positive screens to interventions.
This recommendation applies to women who do not
have signs or symptoms of abuse.
9

10. Screening Patients – Why?
Health impact
 Injuries resulting from physical assaults
 Some are obvious
 Some not visible
 Some can be cumulative or delayed
10

11. Screening Patients – Why?
 Women with a history of IPV had significantly higher
healthcare utilization and costs, continuing long after
IPV ended 7
 PTSD and IPV occur among a sizable proportion of
women referred for headache symptoms.8
 9.8% reported a recent incident of domestic violence
 36.9% reported a lifetime prevalence of domestic
violence
11

12. Screening Patients – Why?
Abused women vs non-abused women9
 Have more headaches, back pain, sexually transmitted
diseases, vaginal bleeding, vaginal infections, pelvic
pain, painful intercourse, urinary tract
infections, appetite loss, abdominal pain, and digestive
problems
 Are 3x more likely to have UTI, PID, STI
 Have a 50% to 70% increase in
 gynecological problems
 central nervous system problems
 stress-related problems
12

13. Screening Patients – Why?
 Adverse childhood experiences, including exposure to
domestic violence, have been linked to a range of
adverse health outcomes in adulthood, including10,11
 substance abuse
 depression
 cardiovascular disease
 diabetes
 cancer
 premature mortality
13

14. Screening Patients – Why?
STRANGULATION
can result in substantial health effects12:
 Physical: dizziness, nausea, sore throat, voice changes,
throat and neck injuries, breathing problems,
swallowing difficulties, ringing in ears, vision change
 Neurological: eyelid droop, facial droop, left or right
side weakness, loss of sensation, loss of memory,
paralysis
 Psychological: PTSD, depression, suicidal ideation,
insomnia
14

15. Screening Patients – Why?
STRANGULATION
Can result in delayed death
 Neck edema may not be visible immediately, but may
develop due to internal hemorrhage and injury to
underlying neck structures. This edema may progress
and compromise the airway causing delayed death.13,14
15

16. Screening Patients – Why?
Affordable Care Act
 Moves from traditional medical model to one of
prevention
 Links between IPV and health costs justifies inclusion
of domestic violence screening as a preventive
measure
 As of January 2104, insurance companies, health care
providers, and health programs that receive federal
funds will be prohibited from denying coverage due to
domestic violence
16

17. Screening Patients – Why?
Affordable Care Act
As of August 2012,
all new and non-grandfathered health plans
must cover screening and counseling
for domestic violence
17

18. Screening Patients – Why?
Affordable Care Act
Congressional intent under ACA
was that screening and assessing for IPV can be
considered a primary prevention
or early intervention service
similar to smoking cessation,
obesity screening, and alcohol misuse
18

19. Screening Patients – Why?
Affordable Care Act
 No specific guidance was provided regarding what
codes to use
 Some groups are exploring using preventive medicine
service codes 99381-99397
 which include age appropriate counseling,
 anticipatory guidance,
 risk factor reduction interventions
 Codes 99401-99412 may be applied for counseling
provided separately, at a different encounter on a
different day
19

20. Screening Patients – How?
 SAFETY is paramount
 Meet privately with patient
 Do not use family or friend to interpret
20

21. Screening Patients – How?
Find a way to get the patient alone,
away from whomever brought her.
 “It’s our policy to conduct the exam in private…”
 “Can you please help me straighten out some
insurance questions?”
Be creative!
21

22. Screening Patients – How?
 Framing Statement
“We’ve started asking all of our female
patients about safe and healthy
relationships because it can have such a
large impact on your health.”
22

23. Screening Patients – How?
Confidentiality
 “Before we get started, I want you to know
that everything here is confidential. That
means that I won’t talk to anyone else about
what is said unless I hear something that
legally requires me to make a report.”
23

24. Screening Patients – How?
 Questions should be direct and clear

Have you ever been in a relationship in which you were
hit, slapped, kicked, choked, or otherwise physically
hurt?

Are you now or have you ever been in a relationship in
which you felt threatened or afraid?
 KNOW how you will follow up
24

25. Screening Patients – How?
 SCREENING TOOLS
 5 tools have demonstrated efficacy15
 3 tools are especially suitable for use in primary
care settings15:
1. HARK – Humiliation, Afraid, Rape, Kick
2. HITS – Hurt, Insult, Threaten, Scream
3. WAST – Woman Abuse Screening Tool16
 Some question remains regarding selfadministered vs. physician administered15,17
25

26. HARK
18
WITHIN THE PAST YEAR HAVE YOU BEEN…
 Humiliated or emotionally abused in other ways by
your partner or ex-partner?
 Have you been afraid of your partner or ex-partner?
 Have you been raped or forced to have any kind of
sexual activity by your partner or ex-partner?
 Have you been kicked, hit, slapped, or otherwise
physically hurt by your partner or ex-partner?
26

27. HARK
 A positive response to ONE OR MORE QUESTION
will identify approximately 81% of the patients who
are experiencing IPV
 100% of patients who respond “yes” to 3 or 4 questions
are experiencing IPV
27

28. Screening Patients – How?
 Responding to a positive screen
 Express concern
 Does patient think it’s safe to go home
 Inform patient about available services
 Assume the patient is not able to or
considering leaving the relationship
28

29. Screening Patients – How?
Responding to a positive screen when there are
children in the home
 The presence of IPV does not automatically warrant
DCF intervention
 Try to let the patient know if you need to report
 Explain why it’s necessary
 Offer to make the call with the patient
 Talking with DCF:
 Identify what the survivor does to protect the child
 Connect the dots between exposure and impact on
child
29

30. Screening Patients – How?
Responding to a positive screen
 CCADV programs provide
 FREE services
 CONFIDENTIAL services (protected by statute)
 SAFETY PLANNING
including
 24 hour hotline
 support groups
 emergency shelter
 work with children
 assistance with orders of protection
 information about IPV and other community resources
30

31. Following Up
 Additional screening
ACOG recommends that their physicians19
 SCREEN at periodic intervals, including during
obstetric care (first prenatal visit, at least once each
trimester, and at the postpartum checkup)
 OFFER ongoing support
 REVIEW available referral options
31

32. Following Up
 As part of the community safety net, you ARE NOT
expected to become experts at domestic violence
 You are asked to
 IDENTIFY patients who have experienced IPV and
 REFER for safety planning, advocacy and support
 Just as you do for other health concern or diagnoses
 Become familiar with the CCADV program in your area
32

33. 33

34. Women who received information about safety
were more likely to report ending a relationship
because the relationship was unhealthy
or because they felt unsafe
REGARDLESS OF WHETHER
THEY HAD DISCLOSED A HISTORY OF IPV20