Planning and Implementing a Mistreatment Response Programin an Acute Care Setting

Acknowledgement: From original materials prepared by Corrine Munoz-Plaza, MPH and Jan Capps, MPH, The Beacon Program, UNC Healthcare.

History. The Beacon Program was funded in 1998 by the North Carolina Governor’s Crime Commission to develop the Effective Practices for Healthcare Response to Domestic Violence project. The goal of the project was to provide technical assistance to five healthcare organizations throughout North Carolina in the planning and development of each site’s own domestic violence response program.

While this website addresses the issue of elder mistreatment, mistreatment happens to persons of all ages. The information in this guide applies to a program in an Acute Care setting for all ages.

Chapter 1: Plan

Chapter 2: Develop

Chapter 3: Implement

Chapter 1: Plan

PLANNING FOR A Mistreatment Response ProgramIN THE ACUTE CARE SETTING

Gain Administrative Support

Gaining “buy-in” from your organization administrators is a necessary step to success. Healthcare organizations have a responsibility to respond to both patients and employees who are mistreated or are victims of domestic violence.

Which administrators might be included:

  • President or CEO
  • Director of Patient Services
  • Director of Women’s and Children’s Services
  • Clinic Managers

First Meeting Topics

  • Reason for healthcare response – Explain why you think the organization needs a response program for issues of mistreatment and domestic violence. Present statistics from your organization or from the community that demonstrate the need. Tell administrators what other data you need and how you plan to collect it before you proceed. Cite community need and current response.
  • Accreditation standards and guidelines – Outline standards from organizations such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and guidelines from the American Medical Association. [PROVIDE WEB CITATIONS]
  • Domestic violence program components – Provide examples of other response programs functioning in organizations similar to yours.
  • Implementing a plan – Present a plan for a response program. Include the personnel, time and funds it will take.

Form a Multidisciplinary Planning Team

  • Inside the acute care setting– A team made up of interested people from various disciplines representing multiple departments will know about different issues that need to be addressed and will have different solutions to offer. If possible, one employee should be allowed time away from regular duties to coordinate and lead the team.
  • Outside the acute care setting –Include representatives of community agencies who have expertise in the mistreatment and domestic violence.

Assess the Situation

Assessments take time and can use precious resources. Your organization may believe they know what they need to do, but proceeding without an assessment may lead to wasted effort and overlooked possibilities. Assessing the current situation and the needs for improvement will:

  • Provide a picture of the current response to mistreatment and domestic violence
  • Determine gaps in the existing services
  • Assess how best to allocate available resources
  • Determine the availability of community resources
  • Start a dialogue with agencies who serve those who are mistreated or are the victims of violence.

Patient Assessment

Ask patients to determine the type of system that will respond to their needs. Determine who (male/female, young/old, racially diverse) and how many patients to sample. You will want to explain why you are asking these questions. Questions might include:

  • Would you discuss mistreatment or domestic violence(someone hurting you or someone you care about and/or someone not providing the care they should) with your healthcare provider?
  • What might keep you from talking to your healthcare provider about mistreatment or domestic violence?
  • Have you ever been asked about mistreatment or domestic violence by a healthcare provider before?
  • Who would you could call for help if you or someone you know were a victim of mistreatment or domestic violence?

Clinician Assessment

Survey a sample of staff that has contact with patients, not just physicians and nurses. Ask about their knowledge of and encounters with mistreatment or domestic violence, especially in regards to patients, to determine what the staff knows and what they do when they encounter a patient who they believe has been mistreated or is a victim of domestic violence. Plan to train these staff when a response program is in place. Questions might include:

  • What do you ask patients about being mistreated or if anyone is hurting them?
  • What might keep you from asking about mistreatment?
  • What do you do if a patient tells you they are being mistreated or hurt?
  • What groups, either in the organization or in the community, help people who are mistreated or are victims of domestic violence? Do you refer patients to these groups?
  • What do you consider your ethical or professional responsibility in identifying, assessing and providing appropriate referrals to patients who are mistreated or are victims of domestic violence?

Healthcare Organization Assessment

Assess the organization to determine what services are currently offered and what new services are needed. These questions might be directed at the administrator who has greatest knowledge about the current services. Questions might include:

  • How does the organization serve victims of mistreatment or domestic violence?
  • What improvements does the organization need to make?
  • What resources are available to address the need?

Community Resources Assessment

Call on community agencies and organizations who address the issues of mistreatment and domestic violence. Support from these agencies may prove invaluable in developing a successful program in the healthcare setting. Some questions to ask include:

  • What services do you offer?
  • What gaps in services exist?
  • What can the acute care setting do to meet the needs of patients?
  • How can we best collaborate?

Intervention Models

Primary Providers

Healthcare providers are trained to ask their patients about mistreatment and domestic violence, assess their safety and needs, document the abuse, and provide referrals and follow-ups as part of routine care for patients. To provide this level of care, healthcare providers are trained in communication and counseling skills and knowledge on a range of issues specific to mistreatment and domestic violence. Providers can refer their patients to local programs to provide follow-up counseling and support programs.

Existing Staff

A sufficient number of designated hospital or practice staff (e.g., patient advocates, case managers, social workers, nurse clinicians) are specifically trained to provide crisis intervention, safety assessment and planning, counseling, referral and follow-up as part of their clinical duties. The primary providers refer identified patients to members of the response team.

Mistreatment Response Program

Healthcare providers inquire about abuse and refer patients to an on-site program for further assessment and intervention. (The Beacon Program uses this model.) While the primary provider can offer initial assessment, documentation and referral, an advocate can provide more extensive services as needed. If an advocate is not available 24 hours a day, providing access to initial crisis intervention and advocacy over the telephone is another alternative.

Pros and Cons of Each Model

Chapter 2: Develop

DEVELOPING A Mistreatment Response Program

A Mistreatment Response Program in the acute care setting will improve the health not only of patients but also the community. Before you begin, ask yourself the following questions:

  • What services currently exist for patients who experience mistreatment and domestic violence?
  • Do the services which exist meet the need? If not, what additional services are needed?
  • What can the acute care organization do to improve the identification, assessment, and intervention with patients experiencing mistreatment and/or domestic violence?
  • How can the acute care organization raise awareness among providers and community members about mistreatment and domestic violence and about the resources for patients?

Program Components – Steps to Developing a Mistreatment Response Program

  1. Mistreatment Multidisciplinary Planning Team
  2. MistreatmentPolicies and Protocols
  3. Clinical Intervention Services
  • Identification
  • Assessment
  • Intervention
  • Documentation of Abuse
  • Discharge planning
  1. Follow-up with Patients
  2. Staff Training and Education
  3. Patient Education
  4. Community Linkages
  5. Determining Program Success

Domestic Violence Multidisciplinary Planning Team

The team should be an ongoing source of support, consultation, and guidance for the Mistreatment Response Program. The success of the program may rest on the involvement and interest of the people chosen to be on the team. The team may need to meet more frequently in the beginning to plan and set clear goals and objectives for the program.

List of team activities

  • Select key personnel from various disciplines who are interested in working as team members.
  • Schedule the first team meeting at a time and place convenient for most members. Let members discuss openly their ideas and develop a plan to move forward.
  • Develop appropriate committees to address various aspects of the program, e.g., policies and protocols, staff training, services to the patients and families.
  • Choose a team leader. Sometimes the choice is obvious and other times it may be necessary to share leadership. The leader should have time to oversee the work of the team and work well with colleagues and the community.
  • Develop a schedule for regular meetings. Supplement meetings with electronic communication.

Domestic Violence Policies and Protocols

This step will establish written policies (general statements outlining how the organization plans to address mistreatment and domestic violence) and protocols (procedures providing instructions on how to respond to a specific situation). Determine how the organization defines policies and procedures and the process used in your organization to develop, approve and distribute them.

Policy: An official and consistent healthcare response to mistreatment and domestic violence. Policies should address the organization’s response on behalf of employees as well as patients who are victims of mistreatment and domestic violence.

Policies should include

  • a definition of mistreatment and domestic violence used by the organization,
  • the organization’s mission and objectives that relate to mistreatment and domestic violence,
  • the reason the organization addresses mistreatment and domestic violence, and
  • the organization’s plan to address mistreatment and domestic violence – screening, confidentiality, documentation, reporting requirements, services, etc.

Healthcare Organizations should develop policies that:

  • Affirm that mistreatment and domestic violence are important health issues.
  • Require staff to respond appropriately to victims.
  • State that protocols are accessible to staff.
  • Require staff to attend training.
  • Assure patient confidentiality.
  • Assure patient and staff safety.

Protocol: The expected standard of care for patients who are mistreated or are victims of domestic violence or have a history of mistreatment or domestic violence. Protocols provide step-by-step instructions for providers and staff on how to address specific situations when treating domestic violence patients. Local area family violence groups may help with screening tools and intervention guidelines.

Mistreatment and Domestic Violence Protocols should include:

  • The purpose and rational for the protocol. A brief statement as to how the protocol can be used and by whom, as well as why the specific protocol has been developed for this setting.
  • Define roles for various staff including physicians, nurses, social workers, security, and patient admitting staff.
  • Procedures and tools for routine screening. Include that all patients will be screened, when they will be screened, and where they should be screened.
  • Procedures and tools for assessment. Tools to determine the lethality of the victim’s situation should assess the risk for further abuse and the needs that the victim may have. Safety planning tools should be available for all victims. Tools in the language of the patient with appropriate translation services will serve those who do not speak English.
  • Procedures and tools for documentation. Decide what information will be included in the patient’s medical record (accessible to all the organization’s providers) or kept separately. Determine what documentation is legally required for those who report that they are victims.
  • Procedures and tools for referral. Develop procedures and tools for reporting information to referral agencies. Have referral information available for victims. Community resources that might be included are safe shelter, counseling, childcare, legal services, social services, etc.

Clinical Intervention Services

A patient may seek medical care because of injury from mistreatment or because of other illness or injury. The patient may be uncomfortable discussing mistreatment and may have never discussed it with anyone else. Staff needs to learn techniques of asking and listening for patient concerns about mistreatment and to validate and support the patient’s situation, not trying to “cure” the problem with simple advice.

Steps to Clinical Intervention

  • Identification – Finding out who has been mistreated.
  • Ask all patients about mistreatment and domestic violence (male and female, young and old) directly (rather than on a written form).
  • Talk in a private setting. Assure confidentiality.
  • Develop tools with questions designed to elicit various types of mistreatment.
  • Use gender-neutral questions that do not assume heterosexuality.
  • Ask questions directly and non-judgmentally
  • Document the patient’s responses

Possible Questions:

Our staff is concerned about our patients’ safety and health so we are asking all our patients these questions.

Physical abuse:

  1. Is anyone hurting you?
  2. Does anyone threaten to harm you in any way?
  3. Do you believe someone controls (or tries to control) you too much?
  4. In the last year, have you been hit, pushed, shoved, punched, or kicked by anyone?
  5. Are there weapons in your house? Do you feel threatened by someone with weapons?

Sexual abuse:

  1. Has anyone forced you to do something sexually that made you uncomfortable?
  2. Does anyone ever force you to have sex or perform sexual acts against your will?
  3. Has anyone ever forced you to have sex when you didn’t want to?

Emotional/psychological abuse:

  1. Are you afraid of anyone?
  2. What happens when you disagree with (partner/caregiver)?
  3. Who makes decisions about things in your life?
  4. Has anyone prevented you from leaving the house, seeing friends, working, or going to school?

Financial abuse:

  1. Do you control your money?
  2. Has anyone spent your money on things you didn’t agree with?
  3. Are you giving money against your will to anyone?

Assessment:The foundation of services that are planned.

  • Assess the safety and risk for future mistreatment:

Questions regarding imminent danger:

  • Is the person who mistreated the patient there now or likely to be there?
  • What would the patient like you to do if the person mistreating them tries to get the patient to leave the acute care setting?
  • Does the patient want you to call security or the police?
  • Does the patient want to leave with the abuser or go to a shelter?
  • Does the patient need to call someone (family member, trusted friend, religious advisor)?
  • Does the patient have a protective order?

Questions regarding long-term safety: Talk calmly and objectively about the potential for future mistreatment. Do not try to frighten patients into doing something (such as leaving their abuser) that they are not ready to do. Empower the patient to make decisions for themselves. Cover issues that have been identified earlier but in more depth. Begin to help the patient plan. Issues of particular concern that may indicate future abuse include.

  • Access to weapons
  • Threats of violence
  • Substance abuse
  • Use of violence in other situations
  • Controlling behavior
  • Assess coping mechanisms:Ask patients how they cope with mistreatment. Determine if they are abusing alcohol or drugs to handle physical or psychological pain. Substance abuse makes it difficult to make rational decisions and improve things for the long term.
  • Assess health status:Document the patient’s physical health, noting any complaints that stem from mistreatment. Document other physical symptoms which may have a connection with mistreatment, e.g., headaches, abdominal pain, musculoskeletal pain. In addition to possible substance abuse, determine if the patient is depressed. If mistreatment has been sexual, evaluate for sexually transmitted diseases.

Intervention

Recognize the Stage of the Victim’s Relationship

Not all individuals are ready to make a change even though they are being mistreated. There are several stages of recognizing the situation and changing it:

  • The individual cannot admit that there is a problem. The victim may not see themselves as victims and may need help understanding the danger of the situation they are in.
  • The individual admits abuse but is not ready or able to change or leave the situation. The victim may need to hear that they do not deserve the abuse and that there are resources to help.
  • The individual is in process of changing or leaving the situation. The victim will need support for his/her decisions and may need referrals for long-term assistance such as education, childcare, and housing. Intervention may include developing a safety plan.
  • The individual recently changed or left the situation. The victim may need support (counseling/support group) and may still need a safety plan.

Develop a Safety Plan – Anyone who has been mistreated needs to have a safety plan.