REGIONAL SANE PROGRAM DEVELOPMENT

1. REGIONAL SANE PROGRAM DEVELOPMENT Office of the Illinois Attorney General Lisa Madigan

2. Scope of the Problem • Scope of sexual assault is staggering • 1 in 7 women in Illinois = 670,000 women (2003) • 18.6% of Illinois women have been raped = 930,000 (2010) • The Illinois Coalition Against Sexual Assault Centers helped 18,349 survivors of sexual assault in FY 2010 • But…5,316 rapes reported to Illinois law enforcement in 2009 Why?

3. Current System of Care Emergency department environment What happens when a sexual assault patient presents to the emergency department? How does the staff respond? How does the patient respond?

4. Best Practice Patient Care • Patient placed in private waiting room or designated examination room immediately following triage* • Medical screening examination by physician or other qualified healthcare professional • Medical-forensic examination and medications ordered by physician* • Specially trained health care provider performs medical-forensic examination (24/7 availability of SANE) • Patient only has to disclose full account of sexual assault to one health care provider (SANE) • One provider completes entire medical-forensic examination (SANE) • Medical-forensic examination begins in a timely fashion (within one hour of ED arrival) *SASETA requirements

5. Best Practice Patient Care • Health care provider spends as much time as needed with patient (one-to-one patient ratio) • Advocate called right away, automatically and remains with patient during medical-forensic examination with patient consent • Informed consent* • STI testing if warranted* • STI prophylaxis medication* • HIV risk assessment* • HIV prophylaxis medication (HIV testing, CBC, serum chemistry, 3-5 days of medication, referral to HIV specialist)* • Hepatitis B/tetanus vaccination if warranted • Pregnancy test* • ECP medication or referral for immediate ECP access* *SASETA requirements

6. Best Practice Patient Care • Evidence collection within 7 days of sexual assault* • Drug Facilitated Sexual Assault assessment and evidence collection* • Head-to-toe physical assessment* • Photography of injuries • Nuclear dye (toluidine blue dye) to assist in genital injury detection • Magnification tool to assist in genital injury detection • Strangulation assessment if warranted • Safety assessment • Detailed patient education and discharge instructions* • HFS Authorization for Payment Voucher issued • Referral to local rape crisis agency, counseling, follow-up examination and victim’s compensation* *SASETA requirements

7. Definition of SANE • A registered nurse who has been specially trained to provide comprehensive care to the sexual assault patient, who demonstrates competency in conducting a medical-forensic exam and the ability to be an expert witness

8. History of SANE • Evolved out of the women’s movement of the 1970’s • First SANE programs: • Memphis – 1974 • Minneapolis – 1977 • Amarillo – 1979 • Illinois - 1999

9. History of SANE in Illinois • Illinois General Assembly charges the Illinois Criminal Justice Information Authority (ICJIA) to conduct the SANE Pilot Program in 1999 • Findings include: • Illinois’ SANE Pilot Program substantially improves community response to victims of sex crimes • Illinois’ SANE Pilot Program improves the quality of evidence collection

10. History of SANE in Illinois • Sexual Assault Survivor Emergency Treatment Act (SASETA) defines SANE in 2002 • "Sexual Assault Nurse Examiner” means a registered nurse who has completed a sexual assault nurse examiner (SANE) training program that meets the Forensic Sexual Assault Nurse Examiner Education Guidelines established by the International Association of Forensic Nurses • A sexual assault nurse examiner may conduct examinations using the sexual assault evidence collection kits, without the presence or participation of a physician

11. History of SANE in Illinois • Office of the Illinois Attorney General (OAG) Lisa Madigan recognized that the response to sexual assault survivors was inadequate • OAG receives grant monies to start the SANE Training Program in 2003 • Goal: • Provide free, consistent, high-quality SANE training throughout Illinois • Improve medical-forensic services to sexual assault survivors

12. History of SANE in Illinois • SANE Training Program Mission: • To increase the number of SANEs working in Illinois by providing high quality, consistent education, and support for registered nurses and other professionals serving sexual assault survivors • Provides free didactic SANE training • Sets clinical training guidelines and provides assistance with requirements • Any sexual assault survivor service provider able to attend • Includes all healthcare providers

13. History of SANE in Illinois • SANE Training Program Provides: • 40-hour Adult/Adolescent (basic) SANE training • 16-hours of online content • 40-hour Pediatric SANE training • 16-hour Advanced SANE training • Adult/Adolescent clinical SANE training • SANE clinical guidelines • To date, over 830 individual nurses attending Attorney General’s Office hosted SANE training • 1194 total attendance

14. History of SANE in Illinois • OAG partnered with the Illinois Hospital Association (IHA) to create a statewide SANE Action Plan • Goals: • Double the number of fully-practicing SANE-trained medical professionals from 75 to 150 • Establish hospital-based SANE programs in each of the 11 trauma regions of the state • Deadline: one year • Press conference held October, 2011 as kick-off

15. Why SANE?

16. “Forensic Nurses play an integral role in bridging the gap between law and medicine. They should be in each and every emergency room.” Joseph Biden, Vice President, United States

17. SANE Program Mission and Goals • SANE program mission: To provide compassionate, objective, comprehensive and timely medical-forensic care to every sexual assault patient • SANE program goals: • To ensure that SA patient is not re-traumatized by healthcare system • To provide best practice SA patient care and medical-forensic examination, including evidence collection, photography and thorough documentation • To evaluate risk and provide treatment to prevent STIs and pregnancy • To provide a safety assessment and crisis intervention • To refer SA patient for follow-up services, including local rape crisis agency • To enhance the ability for law enforcement to investigate and prosecution to successfully prosecute the SA, including expert testimony if needed

18. SANE Program Obstacles • Inadequate funding • Lack of investment and leadership • Lack of understanding of SANE and best-practice SA patient care • Can a registered nurse do that? Speculum placement!

19. Regional SANE Program Development • Steps are fluid and can be completed in any order • Proceed in manner that best fits the program • Regional SANE Checklist provided with 3 sections: • Initiating Hospital Internal Steps • Regional Hospital to Hospital Steps • Community Steps • Process can take 1 to 3 years

20. Initiating Hospital Internal Steps • Assign a point person to work on program development • Need invested staff to lead efforts • Can be full or part time dedicated to SANE

21. Initiating Hospital Internal Steps • Conduct a needs assessment for hospital and region • Needs assessment form provided for guidance • Try to acquire at least one year of data during the same defined timeframe

22. Needs Assessment Questions • How many medical-forensic exams are performed at the initiating hospital and other regional hospitals? • May need to use billing codes or how many SA kits completed • Reach out to surrounding hospitals for data • Utilize local rape crisis agency • Will have data on medical advocacy visits to hospitals • Contact Illinois Hospital Association

23. Needs Assessment Questions • How many sexual assaults occur within local community and region? • Community = city or area • Region = county, EMS region, other • Utilize the Illinois Coalition Against Sexual Assault (ICASA) and local rape crisis • Research national data

24. Needs Assessment Questions • How many sexual assaults are reported to law enforcement? • Look at city and surrounding law enforcement agencies • Look at county sheriff’s office • May be able to acquire data on agency website • Look at FBI Uniform Crime Report for Illinois • http://www.isp.state.il.us/crime/cii2009.cfm

25. Needs Assessment Questions • What is the current protocol and response to sexual assault patients and is it adequate? • Consider: • Is best practice care being provided? • Is standard of patient care equal? • Review response protocol approved by IDPH • Discuss with staff • Review patient charts • Was patient care consistent with response protocol and SASETA? • Reach out to local rape crisis

26. Needs Assessment Questions • Is evidence collection completed properly? • Consider “typical” staff training • Discuss with staff • Reach out to local rape crisis • Reach out to Illinois State Police (ISP) forensic scientists • Find your closest center at: http://www.isp.state.il.us/docs/fslabareamap.pdf • Contact ISP SA liaison Rhonda Carter at 217-782-4975

27. Needs Assessment Questions • Is medical-forensic documentation thorough and helpful for the investigation and successful prosecution? • Consider “typical” staff training • Discuss with staff • Reach out to law enforcement • Reach out to State’s Attorney’s Office • Chart review by SANE expert for feedback

28. Needs Assessment Questions • Does the presence of a sexual assault patient create a strain on the hospital ED? • Consider: • Staff comfort with conducting the exam and evidence collection • Average visit time • Discuss with staff • Observation • Reach out to local rape crisis

29. Regional Hospital to Hospital Steps • Reach out to other area hospitals • Reach out to affiliate and non-affiliate hospitals in same city and/or region • IHA member hospital map provided • Other SANE committed hospitals in your EMS region • Present findings in needs assessment • Discuss collaboration to provide SA patient care • May need to explain benefits of SANE and best practice SA patient care • Discuss different regional SANE program models used nationally

30. Regional Hospital to Hospital Steps • Determine best regional SANE program model and define service area • Two basic regional SANE models: one designated SANE hospital in community vs. team of SANEs that respond to multiple hospitals in community • Program site can be hospital-based housed within ED, hospital-based housed in another location, community-based (clinic setting, in rape crisis agency, etc…) or a combination of hospital and community-based • Program can be commercial, non-profit or government-based • Service area unique to program, can be city-wide to multi-county

31. Regional SANE Program Models • Designated hospital: • All other hospitals transfer sexual assault patient to “designated” SANE or sexual assault treatment center • SANEs on-call and respond to designated hospital or on-shift 24/7 in emergency department • Law enforcement, EMS and rape crisis agency refers or transports all medically stable sexual assault patients to designated SANE hospital • SANEs are employees of the hospital or another agency with privileges to practice at hospital • Medical-forensic examinations performed in a designated room within the emergency department or another hospital space • SANE salary paid by the hospital or state reimbursement program • May have more than one hospital that participates or have a rotating hospital system within the community • Model programs: Memphis, TN; Fort Wayne, IN; Milwaukee, WI; Tulsa, OK; Oklahoma City, OK; Fairfax, VA; Akron, OH; Salt Lake City, UT

32. Regional SANE Program Models • Designated hospital pros: • Staff, supplies, equipment, etc… are all centrally located • Setting familiar and comfortable for SANEs and other hospital staff • Designated hospital cons: • Other hospitals may not want to refer to another facility • Inconvenient for SA patient

33. Regional SANE Program Models • Team of traveling SANEs: • Common float-pool of SANEs that travel to hospitals within the community • SANEs on-call and respond to hospital where patient presents • Patients are not transferred from one hospital to another • SANEs are employees of a system of hospitals or another agency with privileges to practice at hospital • Medical-forensic examinations performed in a designated room within the emergency department • SANE salary paid by the group of hospitals, another agency or state reimbursement program • Model programs: South Carolina; Houston, TX; Boston, MA; Portland, OR; West Virginia

34. Regional SANE Program Models • Team of traveling SANEs pros: • Do not have to transfer/refer patient • More convenient for patient • Team of traveling SANEs cons: • Not convenient for SANEs • Travel costs • Need portable kit/supplies • Decreased comfort level for SANEs and other hospital staff

35. Regional Hospital to Hospital Steps • Determine SANE program location and facility space for medical-forensic exams • Need SANE designated space • Consider: • Comfort of the SA patient • Access to medical support and emergency care • Access to pharmacy and medication • Access to laboratory testing • Access to supplies and equipment

36. Regional Hospital to Hospital Steps • Develop joint policy and procedures for regional SANE program • This may be step that takes the longest • Determine standard response algorithm • Determine response time • Typical is one hour, but must consider travel distance for SANE • Determine how SANEs will be notified and when • Will need a centralized call center • Determine if MOUs and/or transfer agreements are needed

37. Patient Access to SANE Program • How are SANE services accessed: • SA victim reports to law enforcement • Law enforcement notifies SANE of incoming patient and transports to program • SA victim calls local rape crisis hotline • Rape crisis refers to program and notifies SANE of incoming patient • SA victim presents at local hospital for care • If exam site, SANE notified of patient in ED • If not exam site, patient transferred/referred to SANE and hospital notifies SANE of incoming patient

38. Regional Hospital to Hospital Steps • Develop MOUs and transfer agreements between hospitals and other community partners • MOUs needed for SANE privilege to practice at non-employee hospital • Transfer agreements needed if one hospital is transferring to another • Involve hospital legal and risk management departments • Consider EMTALA • Examples of both provided

39. Regional Hospital to Hospital Steps • Submit area-wide sexual assault treatment plan to IDPH • Find IDPH requirements at: http://www.ilga.gov/commission/jcar/admincode/077/077005450000500R.html • Each hospital will still need to be designated as a “treatment” or “transfer” hospital by IDPH • Hospitals involved in area-wide program submit plan together

40. Regional Hospital to Hospital Steps • Create a SANE program budget • Budget worksheet included • SANE model is usually more cost effective than the ED nurse/physician approach • Creates organized, efficient, less time-consuming response • SANEs time more cost effective • Streamlines billing process • SANE program will increase the number of SA patients seen…If you build it, they will come • Determine a per patient cost and projected revenue figure and compare to the current system of care Always consider the quality of patient care that is being delivered under the current system versus the quality utilizing the SANE model

41. SANE Program Budget • SANE services start-up costs to consider: • SANE Coordinator (full or part-time) • SANE staff salary • Training of SANEs • Designated space for medical-forensic examinations, administrative duties, etc…no ED space is more cost effective • Equipment (computer, printer, exam table/chair, magnification tool, digital camera, alternative light source, swab dryer, other)

42. SANE Program Budget • On-going costs to consider: • Salary of ED staff/SANE (physician, nurse, tech, clerk, etc…) • Number of staff that interact with sexual assault patient • Average time of ED visit by sexual assault patient from check-in to discharge • Number of sexual assault patients seen by ED • Administration • Space/examination room • Supplies • Equipment • Laboratory tests • Medications • Training and continuing education for ED staff/SANE

43. SANE Program Budget • On-going revenue to consider: • Reimbursement for patient services • Private insurance • Medicaid/Medicare • Illinois Sexual Assault Program (Medicaid reimbursement rate for uninsured patients) • Private/public grants • Donations • Fundraising • Other (partner agency buy-in, etc…)

44. Regional Hospital to Hospital Steps • Identify SANE program funding sources • Meet with your internal grant and fundraising departments for additional assistance and ideas • Takes creativity, perseverance and hard work • List of potential funding sources provided • Funding sources will be unique to your community

45. SANE Program Funding Sources • Illinois Sexual Assault Program • Reimburses hospitals and other providers (i.e. ambulance, physicians) for medical-forensic services not covered by private insurance or the Illinois Public Aid Code • Administered by the Illinois Department of Healthcare and Family Services • Requires hospital billing form to be submitted within 6 months of service • For more information, contact the Illinois Sexual Assault Program at 217-782-3303 • Violence Against Women Act (VAWA) and Victims of Crime Act (VOCA) grants • Administered by the Illinois Criminal Justice information Authority (ICJIA) • Website: http://www.icjia.state.il.us/public/index.cfm • For more information: 312-793-8550 or cja.grantsunit@illinois.gov • Edward Byrne Memorial Justice Assistance Grant (JAG) Program • Also administered by ICJIA; see information above • Violent Crime Victim Assistance (VCVA) Grant Program • Administered by the Office of the Illinois Attorney General • Website: http://illinoisattorneygeneral.gov/victims/vcva.html • Per statute, must be a non-profit agency that will provide victim assistance to qualify

46. SANE Program Funding Sources • Local and national grants from public and private foundations, corporations, community organizations, or other agencies (i.e. United Way; organizations with a focus on women, children, healthcare, or the community; local business groups; corporation with office in community) • Community fund-raising • Particularly successful for start-up costs or specific equipment • Private donations • Private donors, corporations/businesses, established pool of hospital donors • Annual or on-going hospital employee giving program • Allow employees to specify “SANE program” as an option • Other government funding (i.e. State’s Attorney’s Office, law enforcement agencies) • Other hospitals • If regional SANE model is adapted, transfer hospitals contribute to SANE-designated hospital

47. Regional Hospital to Hospital Steps • Staff SANE Program • SANE Coordinator • Full or part-time • Usually a SANE in coordinator position • Consider reporting structure • Role = overall program operation, including call schedule and staffing, budget, protocol development, staff training, peer review, issue management, etc…and liaison with community agencies • Medical Director • Consider ED medical director or other invested physician • Role = approves protocols, peer review and on-going support • Staff SANEs • Consider non-ED nurses and hiring specifically for SANE • Most important is motivation and assessment skills • Each hospital could tribute to SANE staff

48. Regional Hospital to Hospital Steps • Send SANE staff to SANE training and support and provide SANE clinical training • Utilize free OAG SANE Training Program • SANE training requirements: • 40-hour adult/adolescent didactic SANE training • Combination of online (16-hours) and classroom (24-hours) training • SANE clinical training includes: • Series of activities that can be completed in 25-40 hours • The clinical training includes: • 15 female genital examinations including speculum placement • Observation at a criminal trial proceeding including the direct and cross examination of a witness • 3 out 7 available activities listed on the clinical training log (e.g. visiting a local rape crisis center and attending a 4-hour Illinois State Police Forensic Laboratory training) OR completing a 12-hour Virtual Practicum DVD, Sexual Assault: Forensic and Clinical Management • 3 medical-forensic examinations with a preceptor

49. Regional Hospital to Hospital Steps • Create an on-call schedule or SANE staffing schedule • On-call staffing vs. staff positions • Back-up usually provided by program coordinator • Determine length of SANE shifts • Utilize a calendar program – Yahoo Groups, Google calendar, other • On-call pay?

50. Regional Hospital to Hospital Steps • Obtain necessary supplies and equipment • List of supplies included • Start-up equipment and supplies: • Office equipment (computer, printer, external hard drive, CDs, paper) • Examination table • Digital camera with macro lens setting (consider foot pedal or remote) • Tri-pod • “L-scale” or other measuring device • Colposcope (if funding does not permit, this is optional) • Alternative light source (Woods Lamp) • Swab dyer or swab rack (convenient, but optional)