Domestic Violence Health Care Partnership

State: CA Type: Promising Practice Year: 2016

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Domestic violence is a health care problem of epidemic proportions. In addition to the immediate trauma caused by abuse, domestic violence contributes to a number of chronic health problems, including depression, alcohol and substance abuse, sexually transmitted diseases such as HIV/AIDS, and often limits the ability of victims to manage other chronic illnesses such as diabetes and hypertension. Despite these facts, a critical gap remains in the delivery of health care to domestic violence victims, with many providers discharging a victim with only the presenting injuries being treated, leaving the underlying cause of those injuries un addressed. The goal of the domestic violence (DV) and healthcare safety net partnership was to address and prevent DV through integrated models of service and system-level improvements. In San Bernardino County, a partnership between Family Assistance Program, a non-profit organization, and the County of San Bernardino Department of Public Health Hesperia Health Center, a Federally Qualified Health Center, was established to create a plan that would result in the adoption of policy and procedure changes that incorporate a trauma informed, culturally appropriate response to domestic violence (DV). 

 

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San Bernardino County Department of Public Health
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Domestic Violence Health Care Partnership
The domestic violence (DV) and healthcare safety net partnership is a partnership between Family Assistance Program, a non-profit organization, and the County of San Bernardino Department of Public Hesperia Health Center, a Federally Qualified Health Care Center. Both agencies are located in the High Desert Region of the County. The partnership was established to create a plan that would recommend and adopt policy and procedure changes to incorporate a trauma informed, culturally appropriate response to domestic violence (DV).  The Hesperia Health Center (HHC) represents a population that is racially and ethnically diverse with more than half of the patients identifying as Hispanic/Latino. The county population is racially and ethnically diverse with 49.9% Hispanic; 32.6% White; 7.8% Black or African American; 6.6% Asian or Pacific Islander and 2.7% report two or more races. Less than 1% of the residents are American Indian/Alaska Native. Every 9 seconds in the United States a women is assaulted or beaten. In California, 40% of women experience physical intimate partner violence.  In 2014, there were over 7900 domestic violence related calls for assistance to law enforcement; 2100 of which came from the cities the Hesperia Health Center serves. The goal and objectives of the proposed practice was to develop a healthcare safety net partnership that would address and prevent domestic violence through integrated models of service and system-level improvements. Implementation began with a formalized partnership between Family Assistance Program and Hesperia Health Center. Staffs were cross-trained on screening and identifying domestic violence/sexual assualt, improved skills to respond to DV/SA, domestic violence staff on health care coverage and health needs, and cross-referrals. Together the Family Assistance Program and the County of San Bernardino Public Health Department, Clinic Operations Section has been successful in areas such as bridging gaps, developing training modules and training staff; continuous discussions about domestic violence with patients; increased safety assessment with patients, and increased review of confidentiality. The Domestic Violence Healthcare Partnership has served as a health care safety net for some 119 patients providing them with access to preventive and primary health care, as well as enabling services. The website: www.familyassist.org        
ABSTRACT OF THE PROGRAM: Domestic violence is a health care problem of epidemic proportions. In addition to the immediate trauma caused by abuse, domestic violence contributes to a number of chronic health problems, including depression, alcohol and substance abuse, sexually transmitted diseases such as HIV/AIDS, and often limits the ability of victims to manage other chronic illnesses such as diabetes and hypertension. Despite these facts, a critical gap remains in the delivery of health care to domestic violence victims, with many providers discharging a victim with only the presenting injuries being treated, leaving the underlying cause of those injuries un addressed. The goal of the domestic violence (DV) and healthcare safety net partnership was to address and prevent DV through integrated models of service and system-level improvements. In San Bernardino County, a partnership between Family Assistance Program, a non-profit organization, and the County of San Bernardino Department of Public Health Hesperia Health Center, a Federally Qualified Health Center, was established to create a plan that would result in the adoption of policy and procedure changes that incorporate a trauma informed, culturally appropriate response to domestic violence (DV).  PROBLEM/NEED OF THE PROGRAM: San Bernardino County is the largest county in the state and the contiguous United States. The county covers over 20,000 square miles of land. There are 24 cities and towns in the county and multiple unincorporated communities. The county is commonly divided into three distinct areas, including the Valley Region (sometimes divided into East and West Valley), Mountain Region, and Desert Region: The Valley Region contains the majority of the county’s incorporated areas and is the most populous region. The Mountain Region is primarily comprised of public lands owned and managed by federal and state agencies. The Desert Region is the largest geographical region (over 93% of the County’s land area) and includes parts of the Mojave Desert. The Hesperia Health Center (HHC) represents a population that is racially and ethnically diverse with more than half of the patients identifying as Hispanic/Latino. The county population is racially and ethnically diverse with 49.9% Hispanic; 32.6% White; 7.8% Black or African American; 6.6% Asian or Pacific Islander and 2.7% report two or more races. Less than 1% of the residents are American Indian/Alaska Native. Challenges for the target population include receiving culturally and linguistically competent healthcare, as 40% of the residents of San Bernardino County speak a language other than English at home, and 39% of the HHC patients indicate they are best served in a language other than English. This diversity provides a wide background of native language, cultural beliefs, and attitudes toward healthcare. Every 9 seconds in the United States a women is assaulted or beaten. In California, 40% of women experience physical intimate partner violence. Domestic violence hotlines in California answer on average 80 calls per day from victims who are in danger, need support, and/or resources. The county of San Bernardino population struggles with domestic violence.  In 2014, there were over 7900 domestic violence related calls for assistance to law enforcement; 2100 of which came from the cities the Hesperia Health Center serves. In addition, the county population struggles with violence stressors that are caused by demographic and economic factors. The majority of these stressors lead to or produce violent tendencies. The county has 7 domestic violence shelters to assist victims who are dealing with a DV situation. Women who have experienced domestic violence are 80% more likely to have a stroke and 70% more likely to have heart disease, than women who have not experienced intimate partner violence.
DESCRIPTION OF THE PROGRAM: The Domestic Violence Healthcare Partnership was developed as a program in partnership between Family Assistance Program, a non-profit organization, and the County of San Bernardino Department of Public Health Hesperia Health Center. The emphasis was to provide an avenue for both a private and public entity to work in collaboration to improve health outcomes, as experienced by domestic violence victims.   This partnership was established to create a plan that would recommend and adopt policy and procedure changes to incorporate a trauma informed and culturally and linguistically appropriate response to domestic violence (DV) in the desert region.    Goals for the Program: The goal and objectives of the proposed practice is to: ·        Foster innovations in service delivery by connecting domestic violence and health organizations. ·        Cultivate leadership by building new resources for domestic violence and health practitioners, including trainings. ·        Promote policies and practices that support systematic domestic violence screening in healthcare settings, and other practices that promote early detection and prevention of domestic violence and intimate partner violence. ·        Build the capacity of California domestic violence service providers to connect clients to the healthcare system. Implementation: By June 30, 2014, strengthen and formalize the partnership between Family Assistance Program and Hesperia Health Center by developing a plan to recommend and adopt policy and procedure changes to incorporate a trauma informed, culturally appropriate response to domestic violence (DV). By December 31, 2014, review and revise Hesperia Health Center procedures to screen, refer and serve DV victims receiving care. Develop and deliver cross-training for Family Assistance Program and clinic staff to enhance awareness of domestic violence/intimate partner violence (DV/IPV), strengthen skills in screening for DV/IPV, increase DV staff awareness of health needs and, incorporate new policies and practices to fully integrate domestic violence/sexual assault (DV/SA) responses within the clinic, as well as new practices to improve health awareness and access to health services within Family Assistance Program. Training will include: screening and identifying DV/SA, improved skills to respond to DV/SA, DV staff for health care coverage and health needs, and cross-referrals. By June 30, 2015, screening and referrals between each of the Hesperia Health Center   and nearest DV program will be fully implemented. By December 31, 2015, adopt policy changes for the Hesperia Health Center to ensure trauma informed systems and institutionalize cross-training and referral between Family Assistance Program and Hesperia Health Center. By March 31, 2015 and on March 31, 2016, collect data and generate a report that uses Health Center data to measure the cost savings to the Hesperia Health Center   attributable to the DV advocate. By March 31, 2016, disseminate lessons learned and explore expansion of the model to other local clinics/ Health Centers. By March 31, 2015 and March 31, 2016, participate actively in technical assistance, learning network and evaluation activities offered through Futures Without Violence including attending grantee convening’s twice yearly and reporting data, tools, protocols, and program materials developed through the grant.
USE OF TECHNOLOGY The Hesperia Health Center (HHC) uses technology for operation and management functions. Meditech serves as the HHC main information technology system and allows staff to operate the health center efficiently and effectively on a daily basis.  The system is used for patient appointment scheduling and management, billing for services and managing claims to third party payers. HHC management staffs use the system for reporting on service utilization, patient outcomes, and continuous quality improvement (CQI).   HHC uses other IT systems such as Omnicare for data collection, case management and follow up, the Learning and Management System (LMS) to monitor staff trainings, and the Public Health website to disseminate information.   The project partners utilized a variety of networks and data collection resources to increase efficiency of the project: ·        Learning Network and technical assistance sharing and guidance provided by Futures without Violence as consultants enhanced statistical analysis and reporting of data. ·        Survey and QA/QI Evaluation tools - used to specifically survey project participants (health care and Domestic violence setting) and collect project data, related to services delivery, perceptions and satisfaction. ·        Asset Mapping - encouraged each partner to consider the range of assets and resources available to them that can be marshalled in the course of the program; this included program action plans. ·        Collaboration assessment (survey) - a baseline survey was administered at kick off and follow-up every 6 months. ·        Qualitative interviews - completed with key stakeholders/team members; several completed in summer 2015. ·        Webinars - used to engage grantee and partners to conduct on-going quality improvement education on domestic violence. ·        Survey Monkey - used to gather information from grantee and partner respondents concerning knowledge and attitudes about domestic violence and service delivery to patients.     COST OF THE PROGRAM A Blue Shield of California Foundation Grant Award in the amount of $210,000 was issued to the DV Healthcare Partnership Grantee Family Assistance Program for the period of April 1, 2014 through March 31, 2016. The operating budget is based upon the needs of the target population and funds for personnel and operating expenses such as equipment, travel, training and office supplies necessary to accomplish the service delivery plan. The primary cost associated with the project, in both the development and implementation phases, was labor (salaries and benefits). The staffing complement employed during the project development included a Program Manager and Domestic Violence Advocate, Family Assistance Program; a Public Health Program Manager, County of San Bernardino, Public Health, Hesperia Health Center. The budget included funding for supplies, resources, and education materials to operate the project.   In order to fulfill the Hesperia Health Center (HHC) mission of improving the health status of underserved populations in the County, specifically the high desert region, the HHC provides health care services to DV patients and other in-kind services, as needed.   RESULTS/SUCCESS OF THE PROGRAM Together the Family Assistance Program and the County of San Bernardino Public Health Department, Clinic Operations Section has been successful in the following areas:   ·        Bridging the gap between domestic violence and health care: Through this unique collaboration, these partners are able to provide full-attention to the victims in the local community; this includes having a DV advocate available to cushion the process after disclosure. In addition, victims who make the choice to be survivors and enter into shelter are able to receive medical attention in a timely manner to address their individual health needs. The shelter clients are often able to secure medical services from the Health Center within 5 days of requesting an appointment. During this collaborative process, numerous shelter clients were able to connect to a health care system that may have historically been unavailable or not permitted. For example, a shelter client who had limited access to a health care system was identified as possibly having cancer by the primary care provider, this patient received follow-up treatment/referrals; resulting in a life being saved.   ·        Creation of Training Modules: The project partners strategically worked on the development of training modules to promote awareness and education within the clinical and shelter setting. At the initial out-set, by administering a “Pre-Training Survey”,  this partnership was able to put together a six module training plan to administer to the clinical staff at the County of San Bernardino County Public Health Department, Hesperia Health Center. These trainings were designed to help clinical and paraprofessional staff better approach situations, in which domestic violence/Sexual Assault (DV/ /SA) or Reproductive Sexual Cohesion is disclosed.  The topics developed were able to define terms associated with domestic violence, recommend best practices, improve service delivery and assist staff in engaging in strategies to improve project outcomes. Family Assistance Program assisted the health center staff in having a better understanding of domestic violence and sexual assault, while also assisting with improved utilization and implementation of the Health Center’s existing current protocols and procedures.   ·        Great Relationship Between Entities: Family Assistance Program and the County of San Bernardino County Public Health Department, Clinic Operations Section have come together to create a unique collaboration to better meet the needs of the  community by combining what works with what is needed to improve health. The Public Health, Hesperia Health Center has become accustomed to having the staff of the Family Assistance Program available and ready to assist patients with a warm handoff after the patient has disclosed. In turn, Family Assistance Program has become comfortable with the clinical staff at the Health Center.  The relationship between the partners improves assistance the clients receive to better prepare them for their transition back into the community and violence free life. This is equally true, because clients will know that when domestic violence is disclosed within the health care setting someone will be available to assist with information and resources, thus giving them hope of having a future without abuse. Working together as a partnership has enabled organizations, private and public, to do a better job serving this underserved community.   ·        Collaborative Behavior Change: The implementation of several rounds of behavior surveys were initiated for the period of May 2014 to November 2014, and coordinated by the University of Pittsburgh data collection team. These surveys demonstrated that the Program partners were able to foster innovation to improve health care service delivery through the partnership and shared responsibility. The partners engaged in continuous learning to identify, implement and spread effective policies and practices to address domestic violence and health needs.   ·        Program Level Change: The provision of continuous discussions about domestic violence with patients; increased safety assessment with patients, booster training with staff and increased review of confidentiality. Continuous assessment to identify and address any barriers to intervention implementation.    WORTHINESS OF AWARD The Domestic Violence Healthcare Partnership grows out of, responds to and is owned by the community it serves. It has played a vital role in the delivery of health services to the medically underserved, uninsured and underinsured residents of the High Desert region of the County of San Bernardino. The Domestic Violence Healthcare Partnership has served as a health care safety net for some 119 patients providing them with access to preventive and primary health care, as well as enabling services. This project demonstrates that private and public partnerships can engage in patient health initiatives to develop policies that improve the quality of care for victims of domestic violence, identify gaps in systems and strengthen community partnerships to improve health outcomes.  
SUSTAINABILITY The partners documented and measured the need for sustainability as a domestic violence and health care partnership and the need to focus on sustainable changes. In addition, the partners continue to demonstrate that discussions with patients and clients about domestic violence are increasing and by highlighting system level changes, this can eventually lead to internal/external community policy changes. The partnership recognized the benefits of this partnership in making important system level changes. As the Program approach a new funding year, strategies to sustain collaboration will include cultivating involvement and leadership, building on expertise, track progress on key outcomes, formalize the partnership, plan for inevitable turnover and acknowledge successes and shortfall; make adjustments as needed. The key elements to the Programs sustainability will be enhancing leadership, documentation, data collection; exploration of funding streams and implementing system changes while engaging in policy advocacy.   RESPONDING TO THE ECONOMIC DOWNTURN: During the recent years of economic recession, San Bernardino County has experienced the closure of both industry and local businesses causing more individuals to fall into the low income categories. As a result, there is a loss of health insurance benefits requiring increasing access to low income health care. This partnership helps fill gaps, maximize services and resources to improve domestic violence education to clinical and paraprofessional staff in serving a population with high needs and limited access to services.   COST BENEFIT ANALYSIS A cost benefit analysis has not been completed to identify the cost savings to both partner organizations. The Program partners will engage in this process mid- year two, making the case for continued program need and funding, telling the story of achievements and tracking progress to improve in real-time.  
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