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Service Delivery Innovation Profile

Family Violence Prevention Program Significantly Improves Ability to Identify and Facilitate Treatment for Patients Affected by Domestic Violence


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Snapshot

Summary

Kaiser Permanente Northern California's Family Violence Prevention Program seeks to improve the identification, prevention, and intervention for domestic violence by treating it as a serious health condition and using a "systems model" approach. Program components include the creation of a supportive environment that encourages patients to discuss domestic violence with their providers, routine inquiry of high-risk patients, and referrals to mental health providers and community advocates for victims of domestic violence. The program has led to a sixfold increase in the number of patients identified as being victims of domestic violence, a high percentage of identified patients seeking followup services, and high levels of member satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of rates for identifying domestic violence and for followup care and associations between the responses to specific questions asked in post-implementation satisfaction surveys.
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Developing Organizations

Kaiser Permanente-Northern California
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Use By Other Organizations

  • After the initial pilot study, the program was expanded to 7 more clinics in 2000 and was then disseminated across the Kaiser Permanente Northern California region in 2005, which includes 45 clinics and serves 3.4 million members. Implementation is now under way in all eight Kaiser Permanente regions serving 8.9 million members. Other organizations, such as Partnership Healthplan of California and Contra Costa County Health Services, have adopted the Kaiser Permanente systems model approach, and other health care facilities are using the model to improve their domestic violence prevention services.12

Date First Implemented

1998
The program was initially pilot tested in one Kaiser Permanente Northern California medical facility serving 75,000 members in 1998.

Problem Addressed

Domestic violence is extremely common and associated with a significant clinical and economic burden but often goes unidentified. Physicians are well positioned to discuss domestic violence with patients but may not know how to ask about it, recognize "red flags," or refer patients to appropriate services.
  • A common problem: The National Intimate Partner and Sexual Violence Survey found that one in four women and one in seven men have been a victim of severe intimate partner violence at some point in their lives.1 Although domestic violence can happen to anyone regardless of age, ethnicity, socioeconomic status, or gender, women between the ages of 18 and 44 years are at highest risk.2 The California Women's Health Survey found that 6 percent of California women aged 18 years and older are currently experiencing physical domestic violence.3 A study from Group Health Cooperative found that 8 percent of women health plan members had experienced physical, sexual, or emotional abuse in the previous 12 months, and 15 percent had experienced abuse in the previous 5 years.4
  • Leading to illness, injury, and death: People experiencing domestic violence typically exhibit a wide range of physical and mental health problems, including headaches, chronic pain, gastrointestinal problems, gynecologic symptoms, depression and anxiety, and acute and chronic injuries.4,5,6 Domestic violence is the most common cause of injury in women between ages 18 and 44 years.7 In addition, children who witness domestic violence are more likely to have physical and behavioral problems, as well as long-term adverse health outcomes.8
  • Substantial costs: Domestic violence in the United States accounts for $4 billion in direct medical and mental health care expenses and $1.8 billion in lost productivity costs per year.9 A recent study from Group Health Cooperative demonstrated that annual total health care costs were 19 percent higher in women with a history of physical, sexual, or psychological interpersonal violence compared with women who had never experienced interpersonal violence. Health care utilization was higher for all categories of service among women experiencing interpersonal violence. Excess costs due to interpersonal violence are approximately $19.3 million per year for every 100,000 women enrollees aged 18 to 64 years.5
  • Infrequent clinician screening: Although medical professional organizations recommend screening for domestic violence, few clinicians routinely do so.10,11

What They Did

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Description of the Innovative Activity

The Family Violence Prevention Program seeks to improve the identification, prevention, and treatment of domestic violence by approaching it as a serious health issue that should be "diagnosed" during a physician office visit (just like other health conditions). The program's coordinated approach includes four components: a supportive environment that encourages identification; routine, physician-led inquiry; referral to onsite mental health resources; and linkages to community resources. Information provided in April 2012 indicates that the program has now been implemented in 46 facilities serving 3.4 million members in Northern California. Each component is described in more detail below:
  • Environment that supports identification: Kaiser Permanente Northern California facilities support the disclosure of domestic violence to providers by continually exposing patients to information on the topic. Brochures about domestic violence (in English, Spanish, and Chinese) are placed throughout Kaiser Permanente facilities in areas that are easily accessible to patients, such as physician offices, lounge areas, and restrooms. Other prominently displayed materials include posters (placed in examination rooms) and brochures with local resources. Domestic violence information is available online in text, stories, videos, and podcast. Samples can be seen at http://www.kp.org/domesticviolence.
  • Routine physician inquiry of at-risk patients: Kaiser Permanente providers in all departments routinely inquire about domestic violence as part of general physical examinations for all women between the ages of 18 and 65 years and for male or female patients of any age who present with "red-flag" conditions, such as a suspicious injury, headaches, gastrointestinal or genitourinary conditions, chronic pain, depression, or substance use. Depending on the physician's comfort level with an individual patient, physicians may ask about domestic violence directly ("Within the last year, has your partner hit, slapped, kicked, or otherwise physically hurt you?"; "Are you afraid of your partner?") or as part of the routine update on medications, allergies, or change in health conditions. Most commonly, however, it is part of a relationship-building interaction ("Who do you live with?"; "How are things at home?"; "Do you ever feel physically or emotionally threatened or hurt by your partner/spouse?"). In addition, questions about domestic violence are included in previsit and prenatal care questionnaires; physicians can review this information before the visit and follow up during the visit as needed.
    • Physician resources: Physicians have access to a variety of materials designed to facilitate patient screening, including toolkits to assist with reporting to law enforcement when required, examination room posters that can help facilitate the discussion, pocket reference cards, and online clinician reference information and tools. An intranet site linked to the electronic medical record includes care pathways, referral information to mental health and community resources, and online training for clinicians.
  • Referral to onsite services: When domestic violence is identified, a physician communicates support for the patient, documents the findings, provides community resource information, and refers the patient to onsite services based on an established protocol. Onsite services provided by mental health clinicians include an evaluation for co-occurring psychiatric conditions (e.g., posttraumatic stress disorder, anxiety, and depression), a danger assessment, and assistance with safety planning.
  • Community linkages: The onsite mental health clinicians refer patients to community resources as needed, including 24-hour crisis response services, long-term counseling, support groups, legal assistance, emergency and transitional housing, and children's services.
  • Continuous feedback: Using diagnostic information from automated databases, department- and facility-specific feedback is provided four times a year, which facilitates trending over time and guides local and regional quality improvement efforts. These data are also used to meet one of the National Committee for Quality Assurance health plan accreditation standards (implementation of a behavioral health program demonstrating coordination between primary care and mental health).

Context of the Innovation

Kaiser Permanente Northern California, a not-for-profit integrated health care system, employs approximately 6,000 physicians and 50,000 staff who work at 45 sites around the northern part of the state. Of its 3.4 million members, approximately 1 million are women between the ages of 18 and 65 years, the population at highest risk of domestic violence. Despite recommendations from health care professional organizations such as the American Medical Association, many Kaiser Permanente Northern California clinicians were not consistently screening patients for domestic violence. In 1998, resources were provided to develop and implement a "systems model" pilot program, which showed a dramatic increase in provider identification and referral of patients with domestic violence. Based on this successful pilot, leadership agreed to provide resources to disseminate the "systems model" across Kaiser Permanente Northern California.

Did It Work?

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Results

The program has led to a sixfold increase in the number of patients identified as being victims of domestic violence, a high percentage of these patients receiving followup services, and high levels of member satisfaction.
  • Sixfold increase in patients identified: In 2000, approximately 1,022 patients were diagnosed with domestic violence; by 2008, that figure had increased to more than 4,000. Information provided in April 2012 indicates that in 2011 more than 6,300 patients had been diagnosed. In addition, the site of identification has shifted—most patients are now identified in less acute settings, such as primary care.
  • High followup rates: Since the program began, more than 50 percent of members diagnosed with domestic violence have had a followup visit with a Kaiser Permanente mental health clinician within 60 days.
  • High member satisfaction: An analysis based on 25,000 member satisfaction surveys revealed a strong correlation between recalling the physician asking about home and family relationships and being "very satisfied" with the care received. This was demonstrated across age, gender, and ethnic groups.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of rates for identifying domestic violence and for followup care and associations between the responses to specific questions asked in post-implementation satisfaction surveys.

How They Did It

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Planning and Development Process

Kaiser Permanente Northern California used a four-phase implementation process for the program. Key elements of each phase are highlighted below:
  • Phase 1: Identified physician champions for the project, created an implementation team, and developed a protocol for referral to mental health services for patients identified with domestic violence.
  • Phase 2: Developed clinician tools for evaluation, documentation, and reporting; provided training and tools to mental health clinicians receiving referrals; developed quality-improvement measures; and identified local community domestic violence advocacy organizations.
  • Phase 3: Provided training and tools to physicians and other clinicians and staff via grand rounds, department meetings, videos, and online training modules; placed appropriate materials in examination rooms, waiting areas, and restrooms and created a mechanism for restocking these materials; and established relationships with local community advocacy organizations and law enforcement.
  • Phase 4: Developed an outreach and publicity plan (including placing articles in member newsletters); increased collaboration between medical facility and community advocacy agencies; incorporated assessment, documentation, and referral tools into the electronic medical record; developed online domestic violence and workplace training for managers, brochures for employees, and increased awareness of Kaiser Permanente's Employee Assistance Program as a resource for employees; and incorporated domestic violence training into yearly staff trainings and new employee orientation.

Resources Used and Skills Needed

  • Staffing: The program includes a part-time physician director and a full-time program director and administrative support person to oversee the implementation of the program throughout all the medical facilities and to develop quality improvement data and reports. Information provided in April 2012 indicates that the program is also supported by part-time analytic and health education consultants. Each medical facility has a multidisciplinary team chaired by a physician champion to establish the systems-model approach at their facility, provide training to clinicians and frontline staff, respond to quality improvement data, and ensure that domestic violence identification and referral is part of everyday patient care.
  • Costs: The estimated costs of the program are not available; major expense categories include the salaries of the part-time physician and regional staff listed above, analytical resources for quality improvement data, twice-yearly meetings to provide updates for facility champions and teams, and the production of health education materials.
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Funding Sources

Kaiser Permanente-Northern California
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Tools and Other Resources

Kaiser Permanente Northern California uses its domestic violence prevention program to meet one of the National Committee for Quality Assurance health plan accreditation standards (QI 11 Continuity and Coordination Between Medical and Behavioral Health Care). A complete list of the National Committee for Quality Assurance's standards is available at http://www.ncqa.org.

Adoption Considerations

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Getting Started with This Innovation

  • Identify an MD champion: An MD champion serves as the voice of the program, highlighting domestic violence as an important health issue that should be addressed by clinicians and develops strategies for full implementation of the program.
  • Create a multidisciplinary implementation team: The identification, prevention, and intervention for domestic violence require the involvement of practitioners from multiple disciplines; representatives from each of these disciplines should be involved in program development and implementation.
  • Provide flexibility in screening techniques: Physicians should be given multiple options so they can incorporate domestic violence inquiry into their practices in a way that is comfortable and natural for them.
  • Design a referral protocol: Physicians will be more likely to ask patients about domestic violence if they have a clear, straightforward protocol to guide next steps after identifying a victim of domestic violence and feel confident that the patient will receive services and resources. The protocol should include referral for patients in crisis and noncrisis situations. Mental health clinicians should receive specific domestic violence training so that they are familiar with domestic violence assessment, safety planning materials, and information about local advocacy organizations.
  • Develop a supportive environment: A supportive environment will put domestic violence at the forefront of patients' minds, thus encouraging them to discuss domestic violence with a provider and/or directly access resources. Have resources available in print and online.
  • Partner with domestic violence advocacy services: For facilities or health care organizations that do not have onsite mental health or social work services, the patient should be given resource and crisis information and the opportunity to call a local or national domestic violence hotline while in the clinic. Information about available mental health resources should be offered.

Sustaining This Innovation

  • Identify qualitative and quantitative measures to ensure continuous quality improvement: This will ensure that clinicians and administrators can evaluate the program's impact on an ongoing basis and make adjustments as needed.
  • Include domestic violence prevention as a health plan, facility, and department goal: Striving to meet a goal keeps domestic violence identification and referral present in the thoughts of providers and administrators.
  • Use a consistent approach based on systems-model thinking: When disseminating the program, identify facility-based champions and multidisciplinary teams that will use the "systems-model" approach to domestic violence prevention. Provide regional leadership the resources to ensure consistency of services across facilities/departments; incorporation into new services (particularly call center, electronic medical record, and online); and alignment with other health initiatives.
  • Integrate domestic violence response into existing systems and daily workflow: Incorporate domestic violence into clinical practice processes and tools such as the electronic medical record and advice and call center protocols.

Use By Other Organizations

  • After the initial pilot study, the program was expanded to 7 more clinics in 2000 and was then disseminated across the Kaiser Permanente Northern California region in 2005, which includes 45 clinics and serves 3.4 million members. Implementation is now under way in all eight Kaiser Permanente regions serving 8.9 million members. Other organizations, such as Partnership Healthplan of California and Contra Costa County Health Services, have adopted the Kaiser Permanente systems model approach, and other health care facilities are using the model to improve their domestic violence prevention services.12

Additional Considerations

  • Kaiser Permanente received the Family Violence Prevention Fund 2009 Heroes in Health Award for creating and implementing an innovative and comprehensive approach to domestic violence prevention.
  • Information provided in April 2012 indicates that in 2007, the Kaiser Permanente Family Violence Prevention Program received the National Business Coalition on Health's eValue8 Innovations Award for innovative healthcare programs that set a precedent for other health care organizations to follow nationally.
  • Information provided in April 20102 indicates that the program is also the 2003 Gold winner of the American Association of Health Plans/Wyeth HERA Award. This award honors programs that have made a measurable difference in the lives of women and children.

More Information

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Contact the Innovator

Brigid McCaw, MD, MPH, MS, FACP
Kaiser Permanente Northern California
1950 Franklin St, 13th Fl, Bayside
Oakland, CA 94612
(510) 987-2035
E-mail: brigid.mccaw@kp.org

Innovator Disclosures

Dr. McCaw has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Ahmed A, McCaw B. Mental health services utilization among women experiencing intimate partner violence. Am J Prev Care. 2010;16(10):731-738. [PubMed]

McCaw B, Golding B, Farley M, et al. Domestic violence and abuse, health status, and social functioning. Women Health. 2007;45(2):1-23. [PubMed]

McCaw B, Kotz K. Family violence prevention program: another way to save a life. The Permanente Journal. 2005 Winter;9(1):65-8. [PubMed]

McCaw B, Kotz K. Developing a health system response to intimate partner violence. In: Mitchell C and Anglin E, editors. Intimate partner violence: a health-based perspective. New York: Oxford University Press; 2009.

McCaw B, Bauer H, Berman W, et al. Women referred for on-site domestic violence services in a managed care organization. Women Health. 2002;35(2-3):23-40. [PubMed]

McCaw B, Berman W, Syme S, et al. Beyond screening for domestic violence: a systems model approach in a managed care setting. Am J Prev Med. 2001;21(3):170-6. [PubMed]

(Added April 2012) Wzorek, C. Intimate partner violence. Healthcare Risk Control. Plymouth Meeting, PA: ECRI Institute, 2012.

Footnotes

1 Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011. Available at: http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence. Washington, DC: U.S. Department of Justice, 2000.
3 Adult female victims of intimate partner physical domestic violence, in Data Points. Sacramento, CA: California Women's Health Survey, Office of Women's Health, California Department of Health Services, 2001.
4 Thompson RS, Bonomi AE, Anderson M, et al. Intimate partner violence: prevalence, types, and chronicity in adult women. Am J Prev Med. 2006;30(6):447-57. [PubMed]
5 Rivara F, Anderson ML, Fishman P, et al. Healthcare utilization and costs for women with a history of intimate partner violence. Am J Prev Med. 2007;32(2):89-96. [PubMed]
6 Bonomi AE, Thompson RS, Anderson M, et al. Intimate partner violence and women's physical, mental and social functioning. Am J Prev Med. 2006;30(6):458-66. [PubMed]
7 U.S. Centers for Disease Control and Prevention. Understanding intimate partner violence fact sheet 2006. Available at: http://www.cdc.gov/ncipc/dvp/ipv_factsheet.pdf.
8 Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14(4):245-58. [PubMed]
9 Costs of intimate partner violence against women in the United States. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2003.
10 McCaw B, Kotz K. Family violence prevention program: another way to save a life. The Permanente Journal. 2005 Winter;9(1):65-8. [PubMed]
11 Rodriguez MA, Bauer HM, McLoughlin E, et al. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999;282:468-74. [PubMed]
12 McCaw B. Using a systems-model approach to improving IPV services in a large health-care organization. IOM (Institute of Medicine) Preventing violence against women and children: Workshop summary. Washington, DC: The National Academies Press, 2011.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 29, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.