HERTFORD COUNTY PUBLIC HEALTH AUTHORITY

Sexually Transmitted Disease (STD)

Program Policy and Procedure

TITLE: Domestic Violence Policy

DATE APPROVED: 5/21/2003 Dates Reviewed/Revised: 12/22/16

Revised

APPROVED BY: ______

HCPHA Health Director Personal Health Services Director Medical Director

Policy

The domestic violence policy consists of the following components:

1.  Identify the abuse.

2.  Assess risks and needs

3.  Provide referrals and assistance

4.  Document the abuse

5.  Follow-up

Domestic violence consists of behaviors used by one person in a relationship to control the other. Partners may be married or not married; heterosexual, gay, or lesbian; living together, separated or dating.

Examples of abuse include:

·  name-calling or putdowns

·  keeping a partner from contacting their family or friends

·  withholding money

·  stopping a partner from getting or keeping a job, school, training

·  actual or threatened physical harm to the patient or to children, other family members, and/or pets as means of controlling the patient

·  sexual assault

·  stalking

·  intimidation

·  prevention of patient from keeping medical appointments or carrying through with suggested medical treatment, medication, activity or physical restrictions

Violence can be criminal and includes physical assault (hitting, pushing, shoving, etc.), sexual abuse (unwanted or forced sexual activity), and stalking. Although emotional (name calling, swearing), psychological (intimidation, breaking a patient’s possessions, threats of harm) and financial (allowing the patient no access to their finances or exploitation) abuse are not criminal behaviors, they are forms of abuse and can lead to criminal violence.

The violence takes many forms and can happen all the time or once in a while. An important step to help yourself or someone you know in preventing or stopping violence is recognizing the warning signs listed on the domestic violence “Power and Control Wheel.”

According to the Centers for Disease Control (CDC), Intimate partner violence—or IPV—is actual or threatened physical or sexual violence or psychological and emotional abuse directed toward a spouse, ex-spouse, current or former boyfriend or girlfriend, or current or former dating partner. Intimate partners may be heterosexual or of the same sex. Some of the common terms used to describe intimate partner violence are domestic abuse, spouse abuse, domestic violence, courtship violence, battering, marital rape, and date rape (Saltzman, et al. 1999).

CDC uses the term intimate partner violence because it describes violence that occurs within all types of intimate relationships. Some of the other terms are overlapping and may be used to mean other forms of violence including abuse of elders, children, and siblings.

ANYONE CAN BE A VICTIM! Victims can be of any age, sex, race, culture, religion, education, employment or marital status. Although both men and women can be abused, most victims are women. Children in homes where there is domestic violence are more likely to be abused and/or neglected. Most children in these homes know about the violence. Even if a child is not physically harmed, they may have emotional and behavior problems resulting from the trauma of being exposed to the violence.

The words domestic violence, family violence, battering, and abuse are used interchangeably throughout this document. The definition above applies to all of these words. Although domestic violence may be perpetuated by a man or a woman, the 95% of victims who experience the most serious injuries and abuse are women. Currently, the number one cause of death among pregnant women is homicide by an intimate partner (i.e. spouse, boyfriend, partner or former spouse, boyfriend or partner). Therefore, the period surrounding maternity including at least once post-partum shall be the main focus of screening, although screening may not be limited to maternity patients alone.

The health department’s role in successfully working with battered women is not to have each individual leave their batterer. However, it is this health department’s responsibility to provide a safe environment for our patients to be assessed and disclose they are in a violent relationship. By understanding and training our staff on how domestic violence affects our patients and why it is a health care risk, we as a health care agency can play a unique and vital role in better serving our patients and helping to combat violence in our community.

Women receiving Maternity Care Coordination services will receive screening for domestic violence.

Purpose

To ensure the Hertford County Public Health Authority (including Family Planning, Sexually Transmitted Diseases (STD), Women, Infants and Children (WIC) and any other clinic setting appropriate for screening) patients at risk for experiencing domestic violence are identified and referred to appropriate resources.

Applicable Laws and Rules

§  North Carolina General Statute 50B – Domestic Violence

Position(s) Primarily Responsible

§  Division Director (Personal Health Services Director, WIC Director, etc.)

§  Health Director

§  Medical Director

§  Rostered Nurses and Medical Providers

Procedures

I.  Identify the abuse:

a.  Women will be screened a minimum of once per trimester by the Pregnancy Care Manager (PCM) or a nurse. It may take three or four visits before enough trust is established for the battered patient to answer honestly. It should be explained to ALL patients during the first assessment that domestic violence often occurs during pregnancy and is a serious enough issue that screening will take place during each trimester and at least once post-partum. The screening should include education (for example, a copy of the Power and Control Wheel, see Appendix A) about domestic violence at the time of pregnancy if the patient requests more information or if the nurse/social worker feels it is appropriate even if the client has not screened positive.

b.  All women will be screened in private, away from her partner or family, except in the case when a translator is necessary. The translator should not be a family member or friend.

c.  The Hurt, Insulted, Threatened with Harm and Screamed (HITS) Domestic Violence Screening Tool (see attachment B) should be used. This tool has high sensitivity (30%-100%) and high specificity (86%-99%) and is one of the most studied assessment tools for domestic violence.

1.  Ask questions in an interview style; do not give the questionnaire to patient to fill out independently.

2.  Be direct and specific with your questions and preface the screening with “these are routine questions we ask every patient.”

3.  Preface the screening process with the following disclaimer: If you advise me violence is taking place in front of or directly to a child in your home by a caregiver of that child (i.e. parent, grandparent, guardian, etc.), this is child abuse and must be reported to the Division of Social Services, Child Protective Services Department.

4.  If the health care professional asking the screening questions is unsure of the patients answers and feels there may be violence taking place, you can refer to the criteria for” Learn to recognize the signs of domestic violence” (see attachment C) as a possible way to try and clarify what may be happening with the patient.

II.  Assess risks and needs

a.  If the patient answers “yes” to ANY of the questions on the initial screening tool, the patient will be referred to a domestic violence social worker.

b.  If the designated domestic violence social worker is not available during the screening, offer a private space for the patient to contact the local safe house in order to get immediate counseling regarding safety and referrals. IT IS THE PATIENT’S CHOICE WHETHER TO CALL OR NOT, THEY MAY REFUSE AND THIS IS OK.

c.  In such a case where the health department may not have a designated domestic violence social worker, the PCM or nurse screening will offer a private space for the patient to contact the local safe house at the time of positive screening in order to get immediate counseling on safety, victim’s rights and referrals. This action, the patient’s response (acceptance or decline of any further assistance) and the outcome of that action should be documented in the patient’s chart and continued screening for violence shall take place at each trimester and at least once post-partum.

III.  Provide referrals and assistance

a.  Referral information and fact sheet shall be given (see attachment D).

b.  Safety will be discussed and an additional information sheet on safety will be offered (see attachment F, Safety Plan). In the event the patient speaks only another language such as Spanish, every attempt will be made to either provide referral information in Spanish or provide the patient with a domestic violence hotline or shelter that can provide information in the primary language (see www.hotpeachpages.net for information and referral on domestic violence in 70 different languages).

c.  If the patient indicates abuse is occurring in front of or directly to a child in the home by a caregiver, this is child abuse and a report will be made to the Department of Social Services (DSS). Every effort should be made to explain to the patient why this referral must be made and to notify the patient that DSS will be called and a report will be made as soon as possible.

IV.  Document the abuse

  1. Document the patient’s response verbatim or as close to what she said as possible within the clinic note and keep it in the medical record. Do not include opinion.
  1. Document all the following, if possible:

1.  Location of any injury identified by the patient as resulting from domestic violence or any identifiable injury the patient may state is from an “accident”.

2.  Age of the injury as stated by the patient

3.  Type and cause of each injury as stated by the patient

4.  Any patterns of trauma (i.e. history of battering or sexual trauma as identified by the patient, recurring injuries such as bruising, lacerations, etc., persistent fear of partner or returning home).

5.  Spousal or partner threats of death as stated by the patient

  1. Document intervention provided and referrals in medical record. Also document on the problem list.
  2. File original screening within appropriate sections of the patient chart.
  3. In addition, a safe contact phone number and address should be obtained from the patient and the patient should be asked at each visit if the contact information is still safe to use. If the patient indicates it is not safe to contact by phone or at home, clearly write DO NOT CONTACT in the chart and the specifications of the patient regarding safe ways to set appointments, etc.

V.  Follow-up

  1. The hits HITS Screening Tool (Attachment A) will be repeated at least once during each trimester whether domestic violence has been indicated or not.
  2. If possible, the following questions should also be asked when domestic violence has been indicated and the answers should be documented by the domestic violence counselor, Maternity social worker or nurse providing the screening:

1.  Has the battering continued?

2.  Has the battering escalated?

3.  Do you feel you are in immediate danger?

4.  Have you decided to take any further steps to leave the abusive situation or take action against the abuser?

5.  Have you contacted the local safe house? If so, have you decided to continue working with them toward a safer environment?

6.  Do you need any additional referrals?

7.  Have you read the information provided about a safety plan and are you comfortable with your safety plan?

8.  Is there now a Domestic Violence Protective Order (DVPO) in place? (If the patient indicates yes, ask is if the patient wishes to provide the name and description of the offender so that staff in clinic and at the front desk can be aware if the offender shows up at the health department looking for the patient. If the offender appears staff should contact police and inform patient immediately.)

VI.  Workplace Violence

  1. In the event the abuser is in the health department when the patient screens positive for domestic violence, DO NOT CONFRONT THE BATTERER. Ask the patient if she wants to contact the local safe house or arrange for alternate transportation to a safe location instead of leaving with the abuser. The patient may refuse and go home with the abuser, this is her choice and that is ok. Document assistance was provided and her response.
  2. If the abuser threatens the patient in front of staff or directly poses a threat or threatens a staff member or other patients in the area, staff can call the police and have the abuser removed from the premises.
  3. In the event the abuser’s behavior is immediately threatening to the patient (i.e. he is waiting in the parking lot or waiting room for her and she states she feels he will abuse her) police may be called at the patients request or an individual who can provide alternate transportation to the patient.
  4. In the event a staff member is in an abusive relationship and his/her abuser becomes threatening or harmful to the staff member at work (i.e. harassing phone calls, visits, or stalking) please refer to North Carolina’s “Prevent Workplace Violence” Law, effective December 1, 2004, for options an employer can enforce on behalf of the staff member.

ATTACHMENT A

ATTACHMENT B

Hurt, Insulted, Threatened with Harm and Screamed (HITS) Domestic Violence Screening Tool

Please read each of the following activities and place a check mark in the box that best indicates the frequency with which your partner acts in the way depicted.

Date: ______

Age: ______

Sex: Male _____ Female _____

Race: Caucasian ______African American _____ American Indian _____ Other______

Ethnicity: Hispanic ______Non-Hispanic ______

How often does your partner? / Never / Rarely / Sometimes / Fairly Often / Frequently
1. Physically hurt you
2. Insult or talk down to you
3. Threaten you with harm
4. Scream or curse at you
1 / 2 / 3 / 4 / 5
TOTAL SCORE

Each item is scored from 1-5. Range between 4-20. A score greater than 10 signify that you are at risk of domestic violence abuse, and should seek counseling or help from a domestic violence resource center such as the following: