+ Resources for Health Care Professionals

• Webinars (5/8/2020) from Futures Without Violence on how to assess violence through remote means during COVID-19 Quarantine

• Guidelines for health professionals on approaching IPV conversations during a telemedicine call and a COVID-19 toolkit that can be adapted to publicize and highlight the availability of IPV services

• Futures Without Violence has created this site for HCPs and advocates to learn about the health impacts of IPV, the approach that health care professionals can take to talking about healthy relationships and intimate partner violence, and numerous resources for every level of intervention (individual, building partnerships with advocacy organizations, changing your health system). It is a great place to start learning.

Crisis Prevention Institute put together a blog post with some guidance, specifically for nurses. As doctors are in increasingly high-demand for COVID wards, nurses are critical in addressing non COVID-related ailments and injuries.

• How to access the special enrollment period for survivors of domestic violence to enroll in health insurance through healthcare.gov. Survivors can access enrollment at any time, 24/7
• The Connecticut Coalition Against Domestic Violence’s (CCADV) Health Professional Outreach Project has created two valuable resources:
  • 1) A series of training videos that give information both on the impacts and prevalence of many forms of domestic violence as well as actionable sets of skills for screening and intervention and
  • 2) A toolkit containing a comprehensive screening guide, fact sheets, and reimbursement codes to record screening

• Women’s Law has provided a list of resources for doctors and healthcare workers on legal requirements and guidelines on working with victims of domestic violence and sexual assault

• DV Health Partnerships has collated a large collection of resources on how health care practices have partnered with local DV organizations to address health needs of survivors

• Information on cultural competence in responding to the needs of survivors of DV collated by the National Resource Center on Domestic Violence

  • Responding to the Needs of Immigrant Survivors of Domestic Violence
  • Serving Trans and Non-Binary Survivors
  • Domestic Violence in Latinx Communities
  • Gender Based Violence and Intersecting Challenges Impacting Native American & Alaskan Village Communities
  • Preventing and Responding to Domestic Violence in Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ) Communities

• The US Department of Justice provides this research brief to explain the critical role health care workers play in providing documentation for domestic violence cases, when, and if, they’re brought to court

+ Screening Tools

Sample Screening Checklist: The 5 A’s:

• (1) ASK about domestic violence
  • If this interaction takes place over the phone, think about ways to tailor questions to answers that would not indicate nature of call to bystanders
    • "Are you somewhere where you can talk freely without being overheard? If not, are you able to go into a separate room?"
  • Start indirectly → frame the subject → ask directly
  • Some indirect questions to open the topic might be:
    • How are things going at home?
    • What about stress levels? How are things going at work? At home?
    • How do you feel about the relationships in your life?
    • How does your partner treat you?
    • Are you having any problems with your partner?
  • How you could frame the subject:
    • “Since relationships and personal safety play an important role in a person’s overall health, I always ask about safety at home.”
  • Ask them directly:
    • "Do you feel safe in your current living situation?"
    • HITS screening tool: Hurt you physically? Insult you? Threaten you? Scream at you?
      • Score responses: never (1), rarely (2), sometimes (3), fairly often (4), always (5)
      • Scores >10 are considered positive & counseling is recommended for patients with scores >5
  • Key considerations: ensure privacy, maintain confidentiality and explain limitations, keep a record, express empathy, validate their experience & avoid using language that can be misconstrued as accusatory
• (2) ASSESS patient’s readiness to make change
  • Inquire about any past efforts to change their current situation. It is important that patients not feel judged for failing to remove themselves from an abusive environment
    • For example, you might say, "It sounds like you’re not sure you can address this right now, but it also sounds like it’s important to you to try."
  • A provider’s tone and language should always be open, accessible, and judgment-free
• (3) ADVISE on next steps
  • Acknowledge their experience and state your concern
    • "Thank you for your honesty and for sharing this with me. I know this can be really difficult to talk about. To tell you the truth, I’m concerned about your safety at home with [partner's name]. A lot of my patients experience things like this. There are resources that can help [Share name, phone and a little about your local DV program.] I would be happy to connect you today if that interests you."
  • It is important to help patients’ maintain their autonomy - ask them what their number one concern is before offering solutions

If they are thinking about making a change:

• (4) ASSIST and connect patients with resources
  • Determine immediate safety concerns
  • Discuss specific support services such as advocacy groups, community based organizations counseling, and legal services
  • Help them generate a safety plan
• (5) ARRANGE for a follow-up
  • Establish code words to immediately end the conversation or indicate serious danger over the phone
  • Schedule a follow-up conversation & discuss a safe way to identify yourself over the phone in order to follow-up with patients

If they are not yet ready or able to make a change:

• Avoid judgement or confrontation
  • "You may be right. How would you feel most comfortable moving forward?"
• Restate concern and provide information about available resource
  • “I just want to make sure you understand that I am concerned about your situation and am available to help you figure out some options, if and when you’re ready. In the meantime, I have some resource materials that I’d like to share with you.”

+ Preparing Yourself and Your Organization To Support Survivors of Domestic Violence

Before a Conversation

• Establish protocols within your organization around options for continued follow-up if a person screens positive for domestic violence, as studies suggest ongoing supportive care is the most influential in affecting outcomes for people experiencing domestic violence
• Discuss with your peers what this might look like so that you can offer options to patients: weekly follow-up by someone in your organization, connecting the patient directly with another team member well-versed in social services, or warm handoff to a local DV organization.
• Know your responsibilities! Are you a mandated reporter? Many health care workers are and reporting guidelines can vary by state. It is important to share that information with patients
  • One example for how to do so: "Before we begin with the questions, I want to remind you that our conversation is confidential. I won’t talk to anyone else about what is said unless you give me your permission or I hear something that legally requires me to make a report such as child abuse, abuse of an elderly person or if you are planning to harm yourself or another person." (CCADV)
  • A HIPAA certified resource on When It’s Okay Under HIPAA to Report Domestic Violence
• During COVID-19, these conversations may no longer be happening within an office setting. If this interaction takes place over the phone, think about ways to tailor questions to answers that would not indicate the nature of the call to bystanders
• Especially if conducted over the phone, continue to restate your understanding of the patient’s responses to ensure that you have not misunderstood their answer. These are difficult, yet very important conversations. Be respectful and be specific with your questions. Many may not label their situation as an abusive environment so avoid using words such as “abuse” or “domestic violence”.

Despite screening, many patients will not disclose domestic violence to healthcare professionals. What is most important is that you are able to build a relationship with a patient and share that there are confidential and free resources available for people experiencing domestic violence.

+ Research on Health Professional Screening and Importance of Long-Term Support

• For more long-term, programmatic solutions, Futures Without Violence has put together a manual on How to Create a Health Care-Based Domestic VIolence and Sexual Assault Program.
• JAMA has also highlighted how a large health care organization has used an innovative systems model approach, quality improvement methodology, health information technology (IT), and implementation science to address domestic violence.