Story… why we do the work we do?

1. Abuse Response:Domestic Violence/Safe Mom Safe BabyThe context of our work…Sharain Horn RN MSN IBCLC

2. Story… why we do the work we do? We believe….

3. What Domestic Violence programs and services are offered by Aurora HC? • Domestic Violence Response • System wide staff education • Community Partnerships • Safe Mom, Safe Baby

4. Current Abuse Response Services DV 1.0 fte CNS Includes Safe Mom Safe Baby (since 2005) The Healing Center (since 2001) SATC (20+ yrs) 1.7 RN fte 1.8 SW fte 12+ on-call SANE Volunteer Advocates Community Partners

5. History…. 1991-2000 Informal DV services at ASLMC 2001 Domestic Violence program began with CNS 1.0 FTE 2002 IRB Approved Research Study 2005-2008 ARS-DV added Safe Mom Safe Baby (SMSB) 2008-2011 SMSB Expanded Services, Advocate Added

6. Prevalence of DV in health care Abused women presented to every type of clinical setting in AHC study, 2002 (n = 1268) Kramer A., Lorenzon D, Mueller G. (2004). Prevalence of Intimate Partner Violence and Health Implications for Women Using Emergency Departments and Primary Care Clinics. Women’s Health Issues. 14: 19-29.

7. Prevalence of DV in Health Care Nearly 1 in 3 women presenting to AHC Emergency Departments or clinics reported severe physical abuse or forced sexual activity in their lifetime Kramer A., Lorenzon D, Mueller G. (2004). Prevalence of Intimate Partner Violence and Health Implications for Women Using Emergency Departments and Primary Care Clinics. Women’s Health Issues. 14: 19-29.

8. Prevalence of DV in health care 1 in 7 women presenting to urban emergency departments had experienced severe physical abuse in the past year Kramer A., Lorenzon D, Mueller G. (2004). Prevalence of Intimate Partner Violence and Health Implications for Women Using Emergency Departments and Primary Care Clinics. Women’s Health Issues. 14: 19-29.

9. Health implications of DV Abused women reported significantly lower health ratings than non-abused women (p =.00) Kramer A., Lorenzon D, Mueller G. (2004). Prevalence of Intimate Partner Violence and Health Implications for Women Using Emergency Departments and Primary Care Clinics. Women’s Health Issues. 14: 19-29.

10. Health implications of DV • The majority (63-93%) of women’s health problems • were reported by abused women • headaches • chronic pain • digestive disorders • vaginal bleeding • depression/anxiety

11. Societal Costs • Tangible costs exceed $5.8 billion each year • Productivity • Social/victim services • Police/fire services • Property loss/damage • *Dept Health & Human Services, CDC, National Center for Injury Prevention and • Control. Costs of IPV Against Women in the U.S, NNVAWS. March 2003

12. Potential for cost savings • In addition to the human toll, the resource and economic burden on health systems from IPV is clearly demonstrated • Potential for cost savings from intervention programs is great • Preventing IPV • Lessening its consequences

13. Caregiver Education • Psychosocial Nursing Day • Safe at Home I and II • All Day ED Response to DV • On-line Domestic Violence Modules • Staff Meetings (Nursing, SW, other) • Informal Education

14. Potential health care cost savings Routine Screening Safe Environments that encourage disclosure Increased Identification Patients have more information, support & options Decreased isolation Increased safety Improved health

15. Aurora’s current response to IPV or DV • Health Care Provider Education • Nurses • Social Workers • Physicians/Medical students • Allied Health Professionals • Direct Service to patients/staff • Crisis Intervention • Advocacy/Case management • Patient education • Staff Consultation • Collaborative Partnerships • Internal and external champions

16. Overacrching Goals – Abuse Response Services • Integrated, culturally-sensitive and coordinated response to IPV • Patients feel, hear and see environments throughout AHC that • support disclosure of abuse • enhance personal safety • Skillful assessment and interventions by health care providers • Collaboration with community partners

17. Safe Mom, Safe Baby • A Collaborative Model of Care for Pregnant Women Experiencing Intimate Partner Violence (IPV)

18. The players • Faculty partners • MD & Nurse Midwife • Nurse Case Manager • Community partners • Family violence advocacy • Prenatal and child care coordination • Shelter Resources • AFS

19. Extent of the Problem Intimate partner violence (IPV) during pregnancy is a national and global health-related problem. Associated with • Increased mortality, injury & disability • Worse general health (physical and emotional) • Chronic pain, substance abuse • Reproductive disorders • Poorer pregnancy & fetal outcomes

20. Prevelance Violence during pregnancy is estimated to affect between 3-20% of live births annually Most studies reported a range of 3.9 - 8.3% (NVAWS 2000)

21. Harvard School of Public Health (HSPH) Study (Amer J Obstetrics and Gynecology, 2006) In women experiencing IPV in the year prior to and/or during a recent pregnancy were: • 40-60% more likely than non-abused women to report hypertension, vaginal bleeding, severe nausea, kidney or UTI and hospitalization during pregnancy • 37% more likely to deliver preterm • Their newborns were 17% more likely to be born underweight • Their newborns were >30% more likely to require intensive care upon birth

23. Healthcare • Over-use of health services (even after leaving an abusive relationship) • Unmet needs for services • Strained relationships with healthcare providers

24. Program Design Despite the prevalence of IPV during pregnancy, very little is written about programs designed to address this problem. The majority of articles addressing IPV during pregnancy focus on describing the prevalence or factors associated with abuse . The relatively few publications addressing IPV-related interventions – investigated a single intervention in a clinic or community setting (screening, counseling, non-professional mentoring)

25. SAFE MOM SAFE BABY Is a nurse-led, evidenced based collaborative model of care that: • removes system barriers and silos of service • by creating a seamless continuum of care for pregnant women • within outpatient/in-patient settings as well as the community in which she lives • by helping her engage with caregivers and navigate the complexities of criminal justice, legal and social service systems in the community

26. SMSB Program Goals • Create a consistent and sustainable response to IPV in perinatal health settings • Improve safety behaviors of pregnant abused women • Monitor health outcomes of mothers and infants • Develop a collaborative model of care for survivors of IPV that can be replicated in other health care settings to improve outcomes

27. Objectives Design and Implementation 2005-2008 • Identify abused women via enhanced screening by educated caregivers • Provide targeted assessment & stage-based interventions by a team of nurse case manager and IPV advocate • Enhance the well-being and safety of mother and infant Expansion and Sustainability 2008-2011 • Expand the program institutionally and within community • Provide outreach to Latina community by hiring a bilingual advocate • Plan for and ensure sustainable funding

28. Components of SMSB • Educate caregivers • Responsive, on-site consultation and direct services • Ongoing case management and advocacy

29. SMSB Referrals

30. Healthcare Setting Safe healthcare environment Routine screening every trimester/postpartum “Safety is of the utmost importance for you and your baby” Timely services onsite “As part of comprehensive women’s health, we have a specialist that could continue to talk with you and help with your concerns”

31. Screening ACOG recommends screening every trimester & postpartum Abuse Assessment Screen (AAS) • Have you ever been emotionally or physically abused by your partner or someone important to you? • Within the last year, have you been hit, slapped kicked or otherwise physically hurt by someone • Since you’ve been pregnant, . . . . • Within the last year, has anyone forced you to have sexual activities? • Are you afraid of your partner or anyone you listed? *AAS – Abuse Assessment Screen developed by Nursing Research Consortium on Violence and Abuse - National Consensus Guidelines for Screening Pregnant Women – Family Violence Prevention Fund/ACOG

32. Documentation Electronic Health Record (EPIC) Screening templates Cascading screens for further assessment and interventions Safety Planning Referrals Reporting

33. SMSB direct services • Patient-centered & stage-based interventions • Tangible support i.e. housing, transportation, baby supplies, legal advocacy, restraining orders • Liaison to community services • Ongoing case management up to 6 months post-partum

34. Client SMSB : Assessment • Intake Form • Danger Assessment (Campbell 2004) • Safety Behaviors Assessment (adapted McFarlane 1998) • Edinburgh Postnatal Depression Scale • DVSA (Dienemann and Campbell 1999)

35. Stages of Change DVSA – Domestic Abuse Survivor Assessment (Dienemann & Campbell 1999) by provider and client Movement in stages of change toward healthy behaviors and a life free of abuse - Stage-matched interventions

36. Safety Behaviors SMSB Clients adopted significantly more safety behaviors • Safety Behaviors Assessment (adapted McFarlane 1998) _________________________________________________ Combined 2009-20011 SMSB clients (n=126) SB score at Entry 24.9 SB Score at Closure 27.7* (significant @ p<.05)

37. Birth Outcomes SMSB clients achieved birth outcomes comparable to the overall population of pregnant women delivering at ASMC despite their increased risk for premature and low-birth weight infants

38. Staff • Approximately 1000 caregivers are educated annually regarding domestic violence and health care • Perinatal caregivers receive ongoing pregnancy-specific formal and informal education • Caregivers acknowledge more readiness to screen patients when they know there are onsite resources and additional expertise available to them and their patients

39. Patient Story Healthcare and Community Partnership

40. Outcomes SMSB clients grew in their readiness for change • Marked progression from contemplation to action ______________________________________________ Combined 2005-20011 SMSB clients (n=239) DVSA score at Entry 2.86 DVSA Score at Closure 3.56* (significant @ p<.05) _______________________________________________

41. Safe Mom, Safe Baby- Client Video

42. In closing Addressing Abuse with patients is a process of examining our own personal experiences and attitudes. Abuse is one of the most critical health issues for women and children. The cost of ignoring it is just too great. Addressing this issue does not take too much time it probably saves time and cost in the long run.