Transforming the Health Care Response to Family Violence

Transforming the Health Care Response to Family Violence

Transforming the Health Care Response to Family Violence Liza Eshilian-Oates, MD Physician Leader, Family Violence Prevention Program Southern California Kaiser Permanente May 9, 2017 | KP Resident Elective Health Policy Program Transforming the Health Care Response to Family Violence 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Intimate Partner Violence A pattern of coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive social isolation and intimidation

Perpetrated by someone who is or was involved in an intimate/romantic relationship with the victim Age: 18-64 Occurs in heterosexual and same sex relationships 15% of the victims are male 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Making the Case: Why is IPV an important health care issue? IPV is extremely common The health effects are devastating The health care costs are substantial IPV impacts future generations

Health care interventions make a difference 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Comparison to Other Important Life-Threatening Conditions that Affect Women In the US, each year New cases of breast cancer[1] Number of women dying from cardiovascular disease[2] Women who are injured from IPV[3] 1. 2. 3.

Breast Cancer Facts & Figures. American Cancer Society: Atlanta, GA. 2005-2006. Heart Disease and Stroke Statistics. American Heart Association: 2006. Extent, Nature, and Consequences of Intimate Partner Violence. U.S. Department of Justice: Washington, DC. NCJ 181867, 2000. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. 211,000 484,000 2,000,000 IPV Associated with Many Health Conditions Most common cause of injury in women (18-44 yo) Chronic

Disorders Reproductive Health Somatic Conditions Mental Health Asthma Pelvic Pain

Headache Depression Obesity STI, HIV Fibromyalgia Anxiety Diabetes Cancer

GI Disorders PTSD Arthritis Unintended Eating Cardiovascular Pregnancy Poor

Pregnancy Outcomes (LBW, PTB) (IBS, ulcers) Fatigue Insomnia Chronic Pain Disorders Stroke Cancer 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Disorders Substance Misuse Suicide Failure to recognize and address IPV results in inefficient and ineffective care Incorrect diagnosis Costly and inappropriate tests Treatment failure

Increased utilization Ongoing morbidity Nonadherence 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Region Women Members 18-65 Current IPV+

Annual Additional Cost Colorado: 218,206 8,728 $ 62.4 Million Georgia: 93,506

3,740 $ 26.7 Million Hawaii: 82,147 2,286 $ 23.5 Million Mid-Atlantic States: 218,917

8,757 $ 62.6 Million Northwest: 181,822 7,273 $ 52.0 Million Washington:

214,179 8,567 $ 61.3 Million Northern California: 1,313,533 52,541 $ 375.7 Million Southern California:

1,402,895 56,116 $ 401.2 Million Total 3,725,205 149,008 $ 1.065 Billion

Impact of IPV on KP Annual Additional Health Care Costs due to IPV $28.6 Million /100,000 women enrollees (age 18-65)* $1,065,000,000 every year for KP (all regions) *Source: Rivara, FP (2007) AJPM, updated to reflect 2014 Dollars 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. IPV Impacts Future Generations Children who witness DV May also be victims of abuse One of the Adverse Childhood Experiences (ACEs)

Higher rates of Depression, anxiety Substance abuse Failure in school Becoming victim or perpetrator domestic violence happens at home. help happens here.

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Most women end violent relationships It takes time: on average 3-5 attempts and about 7 years The majority of women do not have recurrent abusive relationships Clinical intervention helps 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Healthcare providers can start the process Talking to a health care provider increases the likelihood of receiving DV services

Receiving DV services increases likelihood of exiting an abusive relationship Exiting abusive relationship is associated with improved physical health One survivor says I didnt leave my husband that day but the physicians words were part of what it took for me to finally leave. My health is completely back to normal now. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Intervention Makes a Difference! Women who talked to their health care provider about the abuse were nearly 4 times more likely to use an intervention I told my doctor I was feeling stressed out. She asked me if I was being abused. I said YES.

And she told me about a group at Richmond Medical Center. I discovered I wasnt the only woman this happens to. https://youtu.be/q2GDQMOGQ5E Now I feel so at peace, my life is better. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Affordable Care Act Screening and counseling for interpersonal and domestic violence included as part of womens preventive health services

Recommends universal screening for childbearing-age women IPV screening and counseling should be core part of womens health services Womens Preventive Health Care Services Committee 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. California State Law (AB890): Screening and Training Since 1995, California state law AB890 requires that health care providers routinely screen for IPV

and that health care organizations train clinicians on detection and treatment because Those experiencing IPV often seek medical care instead of contacting law enforcement Most women have regular contact with health care, providing multiple opportunities for learning about resources 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. California State Law (Penal Code 11160): Reporting Health care providers are required to make a report to law enforcement if they are treating a physical injury due to IPV

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Most women consider the healthcare setting an appropriate place to discuss and seek help for IPV, and they want physicians to ask about IPV In a study of Kaiser Permanente members, 86% felt that all women should be screened for IPV, and 83% would advise others experiencing DV to seek help in the health care setting 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. It Starts with a Clear Goal:

DV Inquiry and Intervention is Part of Everyday Work 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Transforming the Healthcare Response Innovative systems model approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Kaiser Permanentes Innovative Model https://youtu.be/uocoMbCg9N8 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Referral Protocols Builds on existing resources in behavioral health, social services, mental health Clinician training modules Electronic

Medical Record Tools Inquiry and Referral On-site Services Leadership and Oversight Supportive Environment

Community Linkages Member and employee IPV education materials 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Ongoing work to establish and promote community resources Supportive Environment Awareness and Information What is it?

Reaching patients everywhere they contact the health care system Information: restrooms, exam rooms, on-line, podcasts, health ed classes Posters: Let us know, we can help Private time with provider Engaged and informed workforce 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Supportive Environment RoomingPatient AloneMaterials 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Supportive Environment RoomingPrivacy AlonePosters Rooming alone allows for private discussions of sensitive issues, including relationship violence. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Must Address AND InquiryClinician and Referral

Must address patient AND clinician concerns Patient Concerns The doctor: How do I ask about IPV? What do I do when the answer is yes? How can I offer an intervention that is caring, effective, and efficient? The patient: If I disclose, what will happen? Will I be able to access the next set of resources I need? How will this benefit my health? 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Exercise: Opportunities to reduce barriers 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Inquiry and Referral What to do if the answer is yes? Role of the clinician is clear and limited ASK AFFIRM ASSESS DOCUMENT REFER Making the right thing easier to do.

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Inquiry and Referral Using Technology to Improve Care Supporting clinicians: Tools in electronic medical record (EMR) Point-of-care online resources On-line clinician training Engaging patients: Online information for patients Advice Nurses, Call Centers Apps: Circle of 6, 1 Love, MyPlan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Domestic Violence Screening HealthConnect Questionnaire Because violence is so common and it can affect your health, we ask all our patients about abuse. Your answers will be communicated to your provider. 1. Within the past year, has your partner hit, slapped, kicked, or otherwise physically hurt you? Yes No 2. Within the past year, has your partner forced you to participate in unwanted sexual activities? Yes No 3. Are you afraid of your partner? Yes No

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Improving IPV Inquiry Reminders embedded in Healthconnect Domestic Violence Screening Due Triggers in GYN POE Checklist Alert fires every 24 months Triggers in OB POE Checklist Alerts fire for pregnant women at gestational weeks 6-10, 2428, and 36-37 Actions to be taken: Complete Domestic Violence Screening Questionnaire AND enter Screening for Domestic Violence code. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Improving Inquiry:

Prenatal Intake Questionnaire 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Website easily accessible from EMR Provides Clinical Care Path 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Clinician Training Resources How to Ask, How to Respond, and How to Use HC Tools 14-min Online Training (2010)

Clinician Tipsheet Communicating with Patients: Intimate Partner Violence (2012) A Providers Handbook on Culturally Competent Care Chapter: Intimate Partner Violence (2009) 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Making a Difference 6 min video (2013) Clinician training video

Survivor Voices Stories of Courage, Hope, and Recovery (2016) Abuse and Assault Website Family Violence Prevention Program Intranet Site with clinical resources (2005-2014) On-site IPV Response Social Services & Mental Health Triage for other mental health conditions Danger assessment Safety plan

Support groups Referral to community resources 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. On-site IPV Response Options for HOW HOW to do this Customize using local resources Local DV agency provides on-site advocate on-call response to hospital or clinic In house DV-trained staff collaborate w/ DV agency Private place to access help via phone or on-line 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Community Linkages What are they? DV advocacy 24-hour crisis response, safety planning Emergency shelter; transitional housing Other services: counseling, legal services, court advocacy National DV Hotline, Online Chat, Love is Respect Mobile Texting Family Justice Centers 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Transforming the Healthcare Response Innovative systems model approach Implementation and scaling

Quality measures Performance improvement processes Dissemination Plan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Outcome Measures for Initial Pilot Richmond CA medical center caring for 75,000 patients Pre and post survey of systems model Physicians: increased engagement, inquiry and referral 3 fold increase in identification and referral Patients- increase in IPV inquiry, increased satisfaction with healthplan Minimal impact on clinic workflow

Minimal cost (using already available resources) Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting, McCaw B, et al. American Journal of Preventive Medicine, 21(3), 2001. Women Referred for On-site Domestic Violence Services in a Managed Care Organization, McCaw B, et al. Women and Health, 35(2-3), 2002. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Initial success followed by implementation in 7 more facilities This provided the opportunity to Incorporate new learnings Test patient educational materials Revise clinician training Define qualitative and quantitative metrics Identify the tools needed to support clinician

champions and multi-disciplinary teams. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Next step: Scaling up Infrastructure and sponsorship at each medical center Step-wise implementation of System Model Tools for implementation teams Champion and Team roles Templates for referral pathway Clinician and patient education Regular communication with facility based teams Quality improvement measures Executive Regional sponsorship 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Phases of Implementation 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Step-wise Implementation Step 1 Form a local multi-disciplinary team with clinician champion Develop protocol for patients in urgent and non-urgent situations Identify community resources and develop partnerships Step 2 Visible patient education materials Ensure that on-site services are in place

Choose quality measures and annual goals Stakeholder communication and engagement 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Step-wise Implementation Step 3 Clinician training- brief, frequent. Include tools and stories. Trend progress over time DV resources for employees Step 4 Leadership training for champion and teams Link to other initiatives- electronic medical record, chronic conditions Sustain partnerships with community advocacy

Highlight promising practices Stakeholder communication and engagement 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Exercise: How can we measure our work 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Transforming the Healthcare Response Innovative systems model approach Implementation and scaling Quality measures Performance improvement processes

Dissemination Plan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Process Measures have value For example Each medical center has: 1. Physician champion for IPV 2. Multi-disciplinary team to implement the model 3. Protocol for referral to mental health Highlights essential infrastructure element 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

KP Quality Improvement (QI) Measures Uses automated database Makes sense clinically Actionable Linked with national standard National Committee for Quality Assurance (NCQA): QI 11 Demonstration of a health program showing continuity and coordination between medical and behavioral health care. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. KP Northern California: 25-fold Increase in IPV Identification 25,275

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. KP Southern California: Female Members Diagnosed with IPV Regional, all depts, Females age 18-65 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Exercise: How to ensure success as our program grows 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Transforming the Healthcare Response Innovative systems model approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Performance Improvement

Learning from high performers Identifying innovation and promising practices Use of Plan-Do-Study-Act (PDSA) Disseminating best practices Using the established workplace tools (such as EMR) Aligning with other initiatives and strategic goals (reducing disparities, patient safety, care coordination) 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Learning from high performers 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Example of an innovation that became a best practice: IPV screening tool + private time with provider 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Using established tools, aligning with other initiatives: Depression and

Anxiety Screening Tool includes IPV 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Transforming the Healthcare Response Innovative systems model approach Implementation and scaling Quality measures Performance improvement processes Dissemination Plan 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Implementation of IPV Services Underway in Every KP Region

Washington Northwest Northern California Colorado Mid-Atlantic Southern California Georgia Hawaii 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Inter-regional Family Violence Prevention Champions Started in 2007 Adoption of Systems Model approach Health Connect tools Clinical recommendations and workflow Clinical resources (clinician training, patient education materials) Sharing best practices Presentations at National conferences Inclusion of other forms of family violence TDV, EA, CA, and now ACES/TIC and now Common Metric Partnership w/ Ob/gyn IR Chiefs

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. IPV Screening Workflow 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Overview of DV SmartSet Contents 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Patient Education Resources 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Regional Intranet Sites with Clinical Resources Mid-Atlantic Hawaii NCAL 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Accomplishments and Goals by Region Colorado Implementing Domestic Violence Screening and rooming alone in all OB/GYN Clinics DV assessment Smartset, and clinical DV toolkit Rooming alone pilot in primary care Metrics: Health Plan Primary Care Dashboard in 2015

Hawaii DV screening in OB, revised prenatal intake Med/Legal Newsletter on DV Teen dating violence questions on adolescent questionnaire Metrics: Womens Health Northwest Active support from Primary Care Chief Identified and engaged new DV Physician Champion

Continued collaboration w/ social services and health education Georgia Active support from Ob/gyn Chief Identified and engaged new DV Physician Champion Active collaboration w/ advocacy organization 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Accomplishments and Goals by Region Mid-Atlantic States Comprehensive prenatal program including IPV and Early Start services and follow-up Training for nurses to provide brief IPV intervention Metric: Womens Health Dashboard Participation in Maryland Hospital IPV Consortium

Southern California Implementation of OB/GYN IPV Prenatal Screening throughout the region GYN Proactive Office Encounter (POE) includes DV screening Family Violence Symposium Metric: KPHC Physician Dashboard Northern California Rooming alone and DV screening in OB/gyn dept, some AFM and ED. . Metrics: meets NCQA standard, WH Dashboard, MGA dashboard, data for Medicine, MH, ED. Clinician specific dx data 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. 2016 Inter-regional Quality Improvement Metric: IPV Identification Rate Approximately 1.3 million adult women visit KPs OB/Gyn clinics

annually. At least 4% are currently experiencing IPV (approximately 52,000 women members). This data shows the IPV identification rate for 2016. CO: 5.1% (82/1,617) NW: 2.9% (39/1,357) SC: 1.8% (230/12,527) HI: 1.5% (16/1,100) GA: 0.9% (14/1,638) NC: 45.6% (9,620/21,091) # of women with IPV Dx IPV Identification Rate =with current IPV* # of women

*estimated using a 4% prevalence for adult women 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. IPV Identification Rate by Region, 2014Q1 - 2016Q4 Among Women Age 18-65 Seen in OB/Gyn Department 10 9 8 7 6 5.1% 5 4

3 2.9% 2 1.8% 1.5% 0.9% 1 0 2014 Numerator:

2015 2016 Women 18-65 with IPV Dx Denominator: Current Prevalence Estimate (4% of Women Members 18-65 SEEN IN OBGYN) 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Colorad o Northwe st Scal

Hawaii Georgia Vision Kaiser Permanente will be the leader in transforming the healthcare response to interpersonal violence and abuse and A vital partner in community and national efforts to end violence 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Vision for 2020 Links between multiple forms of violence

Trauma informed care Resiliency and strengths based approaches Essential role of community partnerships 2-Generation perspective Collaboration across departments 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. We believe that total health is more than freedom from physical affliction its about mind, body, and spirit. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Q+A 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Contact Information Liza Eshilian-Oates, MD Physician Leader, Family Violence Prevention Program Kaiser Permanente- SCAL [email protected] kp.org/domesticviolence 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Appendix

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Key References Young-Wolff K, Kotz K, McCaw B (2016) Transforming the Health Care Response to Intimate Partner Violence: Addressing Wicked Problems. Journal of the American Medical Association. 315(23): 2517-2518 Chapter 35: Intimate Partner Violence in King T, et al. ed. (2016) Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2nd Edition. Babaria P, McCaw B, Kimberg, L. Miller E, McCaw B, Humphreys B, Mitchell C (2015) Integrating Intimate Partner Violence Assessment and Intervention into Healthcare in the United States: A Systems Approach. Journal of Womens Health. 24(1): 92-99 Decker M, Frattaroli S, McCaw B, et al (2012) Conference proceedings: Transforming the Health Care Response to Intimate Partner Violence and

Taking Best Practices to Scale. Journal of Womens Health 21 (12) 1222-1229 IOM Member Spotlight. Violence Prevention: The Role for Health Systems (2012) IOM (Institute of Medicine) Forum on Global Violence Prevention. Washington, DC 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Descriptions of the KP Systems-Model Approach "Using a Systems-Model Model approach to Improving IPV Services in a Large Health Care Organization". Institute of Medicine. 2011 http://www.iom.edu/Reports/2011/Preventing-Violence-Against-Women-and-Childr en-Workshop-Summary.aspx Developing a Health System Response to Intimate Partner Violence,

McCaw, B, and Kotz, K, Intimate Partner Violence: A Health-Based Perspective, C. Mitchell and D. Anglin ed., Oxford University Press 2009 AHRQ Innovations Solution: Family Violence Prevention Program significantly improves ability to identify and facilitate treatment for patients affected by domestic violence, http://www.innovations.ahrq.gov/content.aspx?id=2343 AHRQ Tool for Assessment of Health System Response http://www.ahrq.gov/research/domesticviol/ 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Journal of the American Medical Association (JAMA) June, 2016 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Addtl KP Research Publications on DV A Description of Midlife Women Experiencing Intimate Partner Violence using Electronic

Medical Record Information. (2016) Journal of Womens Health. 25 (5) 498-504. Eaton A, Temkin T, Fireman B, McCaw B, Kotz K, Amaral D, Bhargava R. Minority Women with HIV or AIDS May Suffer From Violence at the Hands of Intimate Partners, Delaying Necessary Treatment. An interview with Brigid McCaw MD (2015) Kaiser Permanente Institute for Health Policy. Nov.30, 2015. Lee S. A Predictive Model to Help Identify Intimate Partner Violence Using Diagnoses and Phone Calls, Barghava R, Temkin TL, Fireman BH, Eaton A, McCaw B, Kotz KJ, Amaral D. American Journal of Preventive Medicine, 2011. Mental Health Service Referral and Utilization among Women Experiencing Intimate Partner Violence, Ahmed A, McCaw B. Am J of Managed Care, 2010. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Intimate Partner Violence, McCaw, B., A Providers Handbook on Culturally Competent Care: Womens Health, Kaiser Permanente National Diversity Council and Office 2009 Domestic Violence and Abuse, Health Status, and Social Functioning, McCaw B, Golding B, Farley, M, Minkoff J. Women and Health, 45(2), 2007. Family Violence Prevention Program: Another Way to Save a Life, McCaw B, Kotz K.The Permanente Journal 9(1), 2005. Women Referred for On-site Domestic Violence Services in a Managed Care Organization, McCaw B, Bauer H, Berman W, Mooney L, Holmberg M, Hunkeler E. Women and Health, 35(2-3), 2002. Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting, McCaw B, Berman B, Syme L, Hunkeler E. American Journal of Preventive Medicine, 21(3), 2001. 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Kaiser Permanente (KP) Largest, non-profit health plan in United States 10.6 million members nationally serves 7 states and District of Columbia 18,652 doctors; 194,294 employees KP Southern California Region 4 million+ members 7,000+ doctors

14 hospitals 222 outpatient facilities/offices 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Health Care Utilization Among Complex and Costly KPNC Members: Barriers and Facilitators Project Team: Stacy Sterling, Alix Pruzansky, Sandy Bui & Felicia Chi, with Richard Grant, Connie Weisner, and Andrea Altschuler. Editorial consultation and bibliographic assistance from Aggie Hinman and Alison Truman. The DOR study of high utilizers examined what differentiates high cost members from lower cost members, controlling for medical severity and demographic factors.

Findings: Behavioral health was the dominant theme among the high utilizers, a major factor influencing health care utilization and health outcomes. Domestic violence was a significant predictor of high utilization status. A history of adverse childhood experiences (ACEs) predicted not only health problems, which has been well-established in the literature, but also health care costs, even when controlling for medical severity and other factors. Recommendation: The independent effects on costs, of both domestic violence and adverse childhood experiences, controlling for other factors, suggests the value of better screening,

assessment and trauma-informed treatment. For internal informational useInc.only. This studyFamily hasViolence not been released. 2015, The Permanente Medical Group, All rights

reserved. Prevention Program. IPV & sexually transmitted infections (STIs) Women disclosing physical abuse were 3 times more likely to experience an STI. Women disclosing psychological abuse were 2 times more likely to experience an STI. IPV & pregnancy termination Past-year prevalence of physical and/or sexual IPV among women seeking abortion is 14-21%. Lifetime prevalence of physical and/or sexual IPV among women seeking abortion is 27-40%.

80 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Coker et al, 2000 IPV and Chronic Health Problems Center for Disease Control (CDC) Feb 2008

60% more likely to have asthma 70% more likely to have heart disease 80% more likely to have a stroke Twice as likely to be a current smoker 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. Coding for IPV Adult abuse (physical, emotional, or sexual) Spouse or partner violence (physical or sexual) Spouse or partner abuse (emotional) Hx of spouse or partner violence (physical or sexual) Hx of spouse or partner abuse (emotional) Adolescent relationship abuse (physical, emotional)

2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program. 37, 219 KP Patients Identified with IPV 1998-2011 Additional Information: Ethnicity Language Length of Kaiser membership Smoking status BMI Pregnancy within 2 years of IPV diagnosis 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

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