Problem Addressed

Interpersonal violence (IPV) is a safety issue in patient care. Individuals experiencing IPV are less likely to obtain needed medical care, keep appointments, improve health behaviors, and adhere to recommended treatments.¹ IPV can also lead to mental health issues such as depression, substance misuse, and post-traumatic stress disorder.² Mental health problems and substance use disorders (SUDs) are generally underdiagnosed, and any causal link with IPV is often not considered. As with patients experiencing IPV, patients experiencing these conditions may have difficulties managing other chronic conditions, with the potential for increased mortality and morbidity.¹ Additionally, IPV increases the likelihood of a pregnant patient experiencing a high-risk pregnancy, including outcomes such as maternal and infant mortality, preterm birth, low birth weight, and increased substance use during pregnancy.¹

IPV is poorly addressed in most healthcare settings,¹ and missed or delayed diagnoses can lead to unnecessary or incorrect tests, procedures, and treatments and increase morbidity or mortality.² As such, this innovation sought to explore how teaching healthcare teams to provide Universal Education about IPV and screenings for IPV, depression, and alcohol and substance use during a primary care visit could represent a critical opportunity to assess patient experience with these intertwined, detrimental health issues.

Description of the Innovative Activity

A multi-sector partnership program called ARISE (Aspire to Realize Improved Safety and Equity) established the Behavioral Health Vital Signs performance metric and an associated single tool that screens for depression, alcohol, substance use, and IPV. The combined behavioral health approach allowed for the management of competing demands and helped to ensure that Medicaid waiver incentives for depression, alcohol, and SUD benchmarks continued to be met by participating clinics.¹ Designating BHVS as the top (“True North”) metric supported for two years was a key implementation success factor.

The BHVS screening tool includes brief education about the impacts of relationships and experiences on health, as well as six multi-part questions, and it is designed to be accessible to lower literacy populations. It is free of stigmatizing language and is easily translatable into other languages. Four of the included questions have been previously validated as part of other projects. The BHVS screening tool allows patients an opportunity to disclose IPV perpetrated by anyone (including an intimate partner) at any point in their lives. Importantly, the BHVS screening tool prompts patients to think about healing strategies for all of these conditions. As a standard component of the implementation workflow, providers were taught to deliver educational messages to patients and review the checklist of healing strategies to facilitate patient-centered conversations.¹ Each data point for the screening questions is entered in the electronic health record (EHR) in structured data fields that can be extracted to provide feedback reports to the clinics. Positive answers to these survey items prompt further action or follow-up. For example, positive responses to the depression screening questions would prompt the administration of the Patient Health Questionnaire-9 (PHQ-9), a widely-used, validated depression screening tool. However, a paper screener is given to providers so they can view the healing behaviors, as these are not available as structured elements within the EHR. Providers can then put details about these behaviors in the patient note.

ARISE built collaborative partnerships with a domestic violence advocacy organization, a legal aid organization, a trauma-specific treatment organization, and a national nonprofit violence prevention resource center. The creation of these partnerships served to support warm handoffs of the patient between primary care and community services if any necessary follow-on services were identified as a result of the screening.¹

Context of the Innovation

Screening for and addressing mental and behavioral health are accepted, evidence-based practices that define high-quality care with performance metrics and incentives in use at the national level. However, as of April 2021, no such metrics or incentives exist to encourage screening for IPV exposure and to encourage patient education, regardless of IPV disclosure.¹

The University of California, San Francisco implemented ARISE with the San Francisco Health Network (SFHN) serving as a partner and pilot site. Of the SFHN population, 75% is insured by Medicaid, and the innovation was implemented in SFHN’s primary care, youth-focused, and women’s clinics in an effort to target the most impacted groups.¹

Results

The BHVS screening tool greatly increased screening for lifetime experience of IPV, from less than 5% of the clinic patient population to 44% over a 12-month period (June 2018 to June 2019). Given the combined behavioral health approach, implementing the BHVS screening tool also led to an increase in the patient population screened for depression, from approximately 44% to just below 60%. Having the ARISE program in place supported an increase in referral to primary care behavioral health clinicians, community resources, and IPV prevention advocates. Of the patients who met with the ARISE IPV advocate after a warm handoff, 40% attended at least one follow-up visit with a community resource.¹

While the implementers did note a slight decrease in the proportion of screenings resulting in positive identification of patients who have experienced IPV, the total number of patients identified as experiencing IPV increased, which led to an overall increase in the number of individuals who disclosed IPV.¹

Planning and Development Process

When planning for implementation, it is critical to ensure health system leadership buy-in. This buy-in not only supports the prioritization of the initiative, but can also help to ensure that behavioral health teams are integrated into the design of both the screening tool (should any modifications be made to the version tested in this innovation) and the implementation plan. On a related note, should any modification be made to the process and/or screening tool, the project team should ensure that educational materials and screening tool questions are presented in a way that resonates with patients and is important to patient goals.

Resources Used and Skills Needed

Incorporation of behavioral health staff and clinicians within the care team should be considered to support the screening processes, identification of any follow-on services a patient may need, and a holistic approach to intertwined behavioral health concerns. Staff members should be educated to ensure that they understand how these behavioral health issues are connected and appreciate that patients are likely to feel fear and shame about disclosing stigmatized issues. Close relationships with community resources are critical to support patients identified for behavioral health issues and facilitate a warm handoff, preferably onsite whenever possible.

Funding Sources

Grant funding for ARISE was provided by the federal Office on Women’s Health, part of the U.S. Department of Health and Human Services. Prior to this project, the SFHN used funds made available through the federal waiver program for systems redesign to place behavioral health clinicians in all primary care clinics.

Getting Started with This Innovation

Early on in implementation, a standard workflow should be established that ensures patients are screened with the BHVS tool on an annual basis, but flexibilities should be built into how the clinics can choose to roll out the survey tool. Rollout can range from having one provider champion responsible for implementing the BHVS screening to a clinic-wide rollout for a limited number of patients. Regardless of how the BHVS process is initially implemented, it should be ensured that all staff know who the community partners are and how to reach them so that patient needs can be seamlessly met and handoffs to community resources are as warm as possible.

Sustaining This Innovation

The BHVS and SFHN team credits several key factors with their ability to sustain implementation of the BHVS:

• Leveraging existing performance metrics for depression that already had incentive payments associated with them supported implementation of the BHVS screening tool and provided an opportunity to educate staff about the relationship between IPV and co-occurring mental health problems and SUDs.
• Creating the single screening tool and workflow reduced the burden on both patients and staff, and supported tool use even if the staff were not as comfortable, clinically, with IPV.  
• Ensuring that each clinic had flexibility in the rollout to adopt the team-based approach required by either limiting the number of teams involved or the number of patients who received the BHVS.
• Designation of this quality improvement initiative as a top, “True North” initiative, highlighted its importance and relationship to health equity and provided maximally coordinated support for implementation.
• Providing weekly reports at the clinic level on missed opportunities highlighted potential opportunities for improvement.

References/Related Articles

• Kimberg L, Bakken EH, Chen E, Schillinger D. The “Behavioral Health Vital Signs” initiative. NEJM Catalyst. 2019. [Access]
• Kimberg L, Wheeler M. Trauma and trauma-informed care. In: Gerber MR, ed. Trauma-Informed Healthcare Approaches. Springer; 2019:25-56. (PDF)
• Miller E, McCaw B. Intimate partner violence. N Engl J Med. 2019;380(9):850-857. doi:10.1056/NEJMra1807166
• Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: the promise of trauma-informed primary care. Womens Health Issues. 2015;25(3):193-197. PMID: 25965151
• Machtinger EL, Davis KB, Kimberg LS, et al. From treatment to healing: inquiry and response to recent and past trauma in adult health care. Womens Health Issues. 2019;29(2):97-102. doi:10.1016/j.whi.2018.11.003
• Kimberg LS. Addressing intimate partner violence with male patients: a review and introduction of pilot guidelines. J Gen Intern Med. 2008;23(12):2071-2078. doi:10.1007/s11606-008-0755-1
• Look to End Abuse Permanently (LEAP). 2016. Accessed April 28, 2021. https://www.leapsf.org/html/index.shtml 
• Futures Without Violence. IPV Health. 2018. Accessed April 28, 2021. https://ipvhealth.org

Footnotes

1. Kimberg L, Bakken EH, Chen E, Schillinger D. The “Behavioral Health Vital Signs” initiative. NEJM Catalyst. 2019.
2. Miller E, McCaw B. Intimate partner violence. N Engl J Med. 2019;380(9):850-857. doi:10.1056/NEJMra1807166

Date Verified by Innovator

June 4, 2021