January 21, 2019
Authors' Note: Since initial publication of this blog on November 27, 2018, there has been a major development in law and public policy. The Violence Against Women Act (VAWA) -- which funds a range of critical supportive programs for survivors of domestic violence and sexual assault -- expired on December 22, 2018 when the federal government shut-down went into effect. VAWA's expiration jeopardizes the operations and sustainability of many community-based domestic violence/sexual assault service providers, meaning that survivors may have to find shelter, navigate complex legal systems, and seek trauma-informed mental health care without any support. This makes it all the more important that healthcare providers and teams become more proficient in serving domestic violence survivors effectively.
MLPB Blog Post
by Meghan Geary, MD and Jeannine Casselman, JD, MA
November 27, 2018
Domestic Violence Homicide Doesn’t Just Happen:
Moving from Physician Bystander to Advocate
Meghan Geary, MD is an attending physician at the Rhode Island Hospital Center for Primary Care.
Jeannine Casselman, JD is a Program Manager at MLPB.
The physician: Meghan
As the granddaughter of a mailman, I always have stamps in my wallet. When I attached a USPS® Forever Stamp to the envelope containing my patient’s request for funds from a crime survivor’s advocacy group, I thought I was helping her in a minuscule way. It never occurred to me that she would be dead before those funds arrived. Intimate partner violence (IPV) is deadly and not something medical providers are sufficiently equipped to prevent, detect, triage, or treat.
I became a primary care doctor in the year of the #MeToo Movement. As part of my formal medical education, I learned to routinely screen reproductive-age women for IPV as part of a standard protocol. Even with that training, I was under prepared as a healthcare provider to care for women experiencing domestic violence. In hospital medicine, there is an intensive care unit for management of the most life-threatening conditions. But there is no intensive care unit or “treatment algorithm” for IPV. That’s shocking given the morbidity and mortality associated with IPV. One in three women will experience violence from an intimate partner during her lifetime.[i] In 2015 alone, of the 3,500 US-based women who died due to homicide, almost half of those women – like my patient – were killed by a current or former intimate partner.[ii]
My patient had obtained a restraining order and our clinic’s social worker was engaged with her to offer ongoing safety planning. As primary care provider lacking depth in IPV dynamics, I thought this plan was reasonable and that if her abusive partner violated the restraining order and hurt her again, she could call 911 and get safe. “The ED is always open,” I told my patient. While I was taught – accurately – that leaving one’s abuser is the most dangerous time in an abusive relationship with the highest risk of violence escalation, I struggled to operationalize this learning within familiar clinical frameworks. Unlike chest pain or respiratory distress, primary care providers cannot directly intervene with respect to an abuser’s violent and unpredictable conduct. And I knew that my patient was conducting her own risk analysis: at our last visit, she said that her primary goal was to be free – free from abuse at the hands of her husband, free from fear of what he would do to her and free from worry about what he would say to her friends. I just didn’t realize that that appointment would be her last with me.
The attorney: Jeannine
In the last decade, 55 people have been killed by intimate partners in Rhode Island, the state where I live and primarily work.[iii] Laws alone are insufficient to buffer survivors from the myriad health-related risks of domestic violence. As a public interest attorney embedded within care teams to support effective SDOH problem-solving, I have witnessed first-hand clinician unease about how best to support patients experiencing IPV, especially when the most valuable supports (e.g., representation in court proceedings, relocation assistance, behavioral health treatment and family counseling, etc.) often are driven by experts and resources external to the healthcare team. In my legal advising capacity, I often field questions about the legal rights and remedies available for IPV survivors. Healthcare team members should understand that:
- When a survivor attempts to navigate the legal system to secure a restraining order, divorce decree or child support order, they often experience fear, confusion, alienation, and re-traumatization. Every court hearing involves the prospect of direct, proximate contact with one’s abuser – in the parking lot, on the sidewalk, in the courthouse elevator, in the courtroom. In restraining order proceedings, a survivor often attends the hearing alone, without an attorney. If she prevails, a judicial ruling is rendered, paperwork is distributed, and the survivor is sent on her way, many times not understanding the scope and meaning of the protective order.
- The most important thing care teams can do when supporting an IPV survivor is communicate with them in a strengths-based, trauma-informed way that recognizes the survivor is the expert in their own life and safety. This skill and commitment will increase the odds of successful safe hand-off of the patient to expert safety planning and other resources, whether internal or external to the clinic. Consider the patient’s network of social supports. Are they connected to a community-based or religious organization? Is their membership in a cultural or linguistic group a source of support or a challenge – or both? Will immigration status and income impact their ability to access concrete supports such as SNAP (food stamps) or TANF (cash assistance)?
My role as an integrated legal advisor to interdisciplinary pediatric, family medicine, and internal medicine care teams enables the team to spot and navigate interconnected SDOH. Think beyond a clinical practice guideline framework. Supporting patients to identify pathways to safety is not amenable to a rigid algorithm – it must be an honest, flexible, and holistic effort.
Meghan: I hope to honor my patient who lost her life by building my capacity – and that of my clinic colleagues – to engage in strengths-based, trauma-informed care for patients who have disclosed IPV. In the aftermath of my patient’s homicide, I am reflecting on how healthcare teams can better serve IPV survivors, like going beyond the daily clinical work flow and engaging partners from other disciplines and sectors. Partnering with others such as lawyers, researchers, community-based organizations and activists can help other survivors. We need to work together to advocate for a future with less domestic violence.
If you are (or someone you know is) in need of support, contact the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
[i], [ii] Petrosky, Emiko, Janet M. Blair, Carter J. Betz, Katherine A. Fowler, Shane P. D. Jack, and Bridget H. Lyons. 2017. “Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence - United States, 2003-2014.” MMWR. Morbidity and Mortality Weekly Report 66 (28): 741–46
[iii] RI Coalition Against Domestic Violence; http://www.ricadv.org/en/what-we-do/communications/news-releases/?open=1 (accessed 11/13/18)
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Accountable care − accountable to whom and for what? Health workforces in Massachusetts and across the nation enter a new normal with SDOH in the job description. As Medicaid ACOs (accountable care organizations) stood up in Massachusetts yesterday and operate in many states across the country, social determinants of health (SDOH) represent a critical frontier of care delivery innovation, workforce quality and satisfaction, cost reduction potential, and health equity progress. Recent developments show promise:
- Housing is now accepted as a "foundational" social determinant of health, with analogies to housing as a "prescription" and "vaccine" being increasingly mainstream. This will support sound priority-setting by health and human services organizations and workforces, and likely will accelerate population-level improvements in housing stability through system and policy change levers informed by large data sets.
- Social risk factors – like housing and neighborhood conditions – are making their way into innovative risk adjustment formulas that drive health financing. This "new math" accounting for SDOH could make it easier for the workforce to sustainably supply more of the services that people actually need to get and stay healthy.
Yet leadership has much work to do:
- Population management is not the same as health equity advancement. Only when systems are incentivized to look beyond the highest-of-high utilization members can meaningful progress on health equity be achieved. An innovative framework for data collection on health disparities in pediatrics is now available to organizations and communities who are pursuing a life course approach to health and wellness.
- The "screen + refer" paradigm driving nascent SDOH care implementation is problematic for many reasons, including the Bridge to Nowhere challenge. And the focus on systematically outsourcing SDOH solutions ignores the fact that plenty of SDOH interventions must happen within the four walls of the health clinic or hospital.
- Health and human services workforces need a blueprint for the central roles they will play in social health integration. Their work comes with great responsibility and some risk – risk that vulnerable individuals, families, and communities will be (further) alienated from health services; risk that workforce members who are not adequately supported will burn out; risk that employers will churn talented staff and fail to meet performance targets; and risk that the health and human services sector simply will not meet the quality and cost imperatives that inspired delivery system transformation in the first place. It’s early days, but exciting new strategies are emerging with demonstrated impact.
Through a blog series for workforce leaders in 2018, MLPB will dive deeper on each of these topics. In the meantime, we are grateful to the organizations with whom we are collaborating in this new landscape – one that promises to better meet the needs of individuals, families and communities through more integrated, human-centered systems and services.
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