What Do Professionals Need to Know?
Health Care Policy
Model Domestic Violence
Policy for Counties
In addition to suffering injuries from physical attacks by
their abusers, victims of domestic violence often suffer a wide
range of health-related problems caused or exacerbated by the
abuse, problems for which an apparent etiology is often lacking.
Victims frequently present to the health care system with an
array of complaints including, but not limited to, headaches and
migraines, musculoskeletal complaints, fatigue, insomnia, anxiety
symptoms such as palpitations and hyperventilation,
gastrointestinal disorders, eating disorders, and chronic pain.
In addition to these common complaints, victims of domestic
violence may also be at increased risk of contracting HIV and
other sexually transmitted diseases, of developing alcohol/other
drug problems, depression, and suicidal ideation. Further,
abusers' physical attacks often result in distinct injury
patterns that are"red flags"for identifying abuse
including, but not limited to, injuries during pregnancy,
bilateral injuries, multiple injuries in various stages of
healing, patterned injuries, defensive injuries, and fractures,
particularly of the nose and eyes.
Despite the common clues and indicators of domestic violence
that emerge in the health care system, research consistently
indicates that a majority of health care providers fail to
identify patients as victims and that this failure leads to a
medical response that provides symptomatic treatment without
addressing the underlying health threat-the violence.(22) Even when domestic violence is identified, it is
often viewed as having little or no clinical significance.
Without appropriate intervention, victims are at increased risk
of developing serious, complex medical and psychosocial
problems.
Research also indicates that battered women continuously seek
help from the health care system and that health care providers
are frequently the first or only professionals with whom they
have contact.(23) Early identification,
appropriate treatment, documentation, and referral of victims who
seek health care may be one of the most effective ways to prevent
repeated injury, pregnancy complications, and the multiple
medical and psychosocial sequelae associated with ongoing
abuse.
The health care system is itself a vast array of systems
including, but not limited to, emergency medical services,
medical transport services, hospitals, clinics, private
practitioners including dentists, obstetricians, and
gynecologists, managed care organizations (HMO's), county
public health agencies, home health care providers, visiting
nurse associations, rehabilitation centers, and veterans'
health facilities. It is critical that all segments of the health
care system respond appropriately and consistently. Many times,
victims will be seen solely by one part of the system, such as
emergency medical services. At other times, they may receive an
array of health care services, such as from hospitals, health
maintenance organization clinics, and private practitioners. It
is crucial that all health care services within a county be
represented in any county-wide attempt to develop and coordinate
services for victims of domestic violence.
In addition to incorporating the recommendations outlined in the Guiding Principles and the Employers sections into their responses to domestic violence, and being mindful of the potential need for individualized responses based on factors such as socio-economic status, race, ethnicity, sexual orientation, age, religious affiliation, physical and mental disabilities, immigrant status, education, employment status, urban vs. rural residency, and marital status, health care providers should also integrate the following recommendations specific to the health care system.
- VICTIM SAFETY AND SELF-DETERMINATION
- Private, routine screening for domestic violence
should be conducted with all female patients to determine if they
are being abused by their intimate partners.
Because domestic violence and its medical and psychiatric consequences for women are so prevalent, both the New York State Department of Health's protocol, Identifying and Treating Adult Victims of Domestic Violence, and the American Medical Association's Diagnostic and Treatment Guidelines on Adult Domestic Violence, recommend routine screening of all women patients for domestic violence. In addition, the AMA Guidelines recommend routine screening of all women patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings. Some recent research recommends more intensive screening for"high risk"populations including pregnant and suicidal women.
Including a screening question for domestic violence in routine questionnaires increases identification significantly. When a female patient is either identified or strongly suspected of being a victim of domestic violence, it is incumbent upon the health care provider to engage in a more intensive screening process.
In order to maintain patient confidentiality and safety, patients should always be screened alone and out of earshot and eyesight of any accompanying partners, as well as being screened away from their children who may repeat information to the patient's partner. Police should be called only to report legally mandated injuries or with the patient's knowledge and consent. Current Penal Law requires the reporting of gunshot and stab wounds, and life-threatening injuries to the local police. Burn injuries and wounds must be reported to the Office of Fire Prevention and Control.
Male victims of domestic violence present to the health care system so infrequently that routine screening of male patients for victimization is not typically recommended. However, male patients who exhibit clinical clues and indicators of abuse should be screened for domestic violence and knowledgeable referrals to resources should be made for these patients.
- Health care providers working in hospitals and
diagnostic and treatment centers must provide a copy of
the Victim's Rights Notice to all suspected and confirmed
victims of domestic violence. All other health care providers
should provide a copy of the Notice to all suspected and
confirmed victims.
Under the Family Protection and Domestic Violence Intervention Act of 1994, all hospitals and diagnostic and treatment centers in New York State are required to provide a copy of the Victim's Rights Notice to all suspected and confirmed victims of domestic violence. While not required to by law, other health care providers should also provide a Victim's Rights Notice to patients who are suspected or confirmed victims of domestic violence.
The Victim's Rights Notice provides information, in both English and Spanish, on the assistance available to victims of domestic violence from the police, Family Court, and criminal court, and also provides statewide and local domestic violence hotline numbers. (The Notice has also been translated into Russian, Arabic, and Chinese. Copies are available through OPDV.)
- Health care providers working in hospitals with
maternity/newborn services and diagnostic and treatment centers
that offer prenatal care services must disseminate
information about the effects of domestic violence and the
services available to women and children who are victims. All
other health care providers who treat pregnant and post-partum
patients should disseminate this same information.
In New York State, Chapter 271 of the Laws of 1997 requires hospitals that have maternity/newborn services, and diagnostic and treatment centers that offer prenatal care services (health centers, Planned Parenthoods, some HMO's, etc.), to disseminate to all patients at prenatal visits, or post-delivery, a notice regarding family violence. The law takes effect on January 23, 1998. The notice will provide information about the effects of child abuse/maltreatment and domestic violence and the services available to women and children who are victims.
In addition to those health care providers who must disseminate this notice in compliance with the law, other health care providers should also provide this notice to pregnant and post-partum patients.
- When domestic violence is identified, health care
providers should collaborate with the victim in evaluating her
ability to comply with recommended treatments and follow-up care,
and should modify prescribed regimens, when necessary, in order
to better achieve health and safety for the victim.
The ability of victims to follow through on recommended treatments can be compromised by the actions of their abusive partners. Victims should not be expected to comply with medical regimens that require them to do things that directly or indirectly endanger them. Health care providers should integrate safety planning into a victim's treatment plan in order to reduce the risk of further harm from her abusive partner and to increase the chances of a successful treatment outcome. Providers should coordinate safety planning efforts with a domestic violence service provider, if a victim so desires. See (See Guiding Principles, 1.d., re: safety planning.)
- Health care providers should recognize that, at
times, legitimate survival and safety strategies employed by
victims (such as resistance, non-compliance and dishonesty) may
conflict with recommended treatments and follow-up care.
Recommended treatments and/or follow-up care should be
continually reviewed and modified, as necessary, to reflect a
victim's ongoing safety-related needs.
The safety-related concerns of victims do not necessarily remain constant. As a result, victims may attempt to protect themselves from the violent and coercive acts of their partners in ways that conflict with agreed upon medical regimens. A victim's use of survival strategies related to safety should be supported and encouraged and not seen as a failure to comply with the treatment plan, but as an indication that the treatment plan needs to be reviewed and modified.
- Health care providers should cultivate cooperative
relationships with domestic violence service providers, advise
patients who are identified as victims of the availability of
domestic violence residential and non-residential services, and
assist women in making linkages with those services if they
desire.
Health care providers should also advise patients who are victims of domestic violence of any in-house services that may be helpful such as a domestic violence coordinator, or the social work department. Health care providers should not refer victims to couples counseling, marital counseling, and/or mediation services; these are all contraindicated in cases of domestic violence. (See Guiding Principles, 1.i.)
- For patients who are victims of domestic violence and
who are also alcohol/other drug-involved, health care providers
should be alert to the possibility of prescription drug abuse
and/or addiction and should weigh carefully the risks and
benefits of prescribing drugs to victims for symptom
relief.
Many chemically dependent victims begin to use substances as a way to manage their fear and cope with the physical and emotional effects of the battering. The success of a safety strategy, however, can be compromised by continued drug use. Health care providers who prescribe medications should carefully weigh the benefits of a given drug against the possible negative effects of that same drug. Particular attention should be given to medications that may affect a victim's cognitive or motor abilities in such a way that she may be compromised in her ability to protect herself from a physical assault, flee from a violent attack, or otherwise respond quickly to a potentially life-threatening situation.
In addition, the success of substance abuse treatment can be compromised by continued violence. An important role, therefore, for health care providers is helping a victim make the connection, when appropriate, between her health problems and the battering. It is helpful to acknowledge the role that the chemicals may play in victims' attempts to cope with the violence and to express a willingness to assist women in accessing help for both problems. Inform the patient that her alcohol or other drug use is not the cause of the violence though her partner may use that as an excuse for his violent behavior. Accurate and supportive information can empower her to make decisions that enhance her safety and therefore reduce her risk of future injury and illness. (See Substance Abuse Treatment System.)
- Health care providers engaged in discharge planning
should ensure that any patient who is an identified victim of
domestic violence or who the health care provider strongly
believes is a victim of domestic violence, has a safe place to go
upon discharge.
Under hospital requirements from the NYS Department of Health, Title X Rules and Regulations Part 405.9 10 NYCRR, hospitals are required to ensure that each patient has a discharge plan which meets the patient's post-hospital needs. In addition, the hospital is responsible for ensuring that the discharge planning staff have current information available regarding support services within the hospital's primary service area including their range of services, admission and discharge polices, and payment criteria.
Therefore, health care providers engaged in discharge planning should be very familiar with the local domestic violence services in their area and be able to describe the range of services available, i.e., residential and non-residential services and how to access those services. The patient should be provided both written and verbal information about local domestic violence services and should be provided the opportunity to speak directly with the local domestic violence service provider, if desired.
No victim should be discharged if the patient states it is unsafe for her to return home and that she has no alternative safe place to stay. Hospitals must either hold the victim in their facility or work with the victim to identify a safe and appropriate option. The patient should retain the right to determine what options will meet her safety-related needs.
- When making referrals, and in particular, when
referring to mental health providers or substance abuse treatment
programs, health care providers, with the victim's consent,
should inform the provider of the patient's history of
domestic violence and related safety needs. Health care providers
should refer victims to practitioners in these settings who are
knowledgeable of and experienced with the provision of
appropriate treatment and services to victims and who prioritize
victim safety and abuser accountability. (See Mental Health System and Substance Abuse Treatment System.)
Referral to mental health services and/or substance abuse treatment services should not be made in lieu of a referral to the local domestic violence service provider, but in those cases in which the specific services are either clinically indicated and/or requested by the patient. In all cases, a referral should be made to the local domestic violence service provider.
- Health care providers should keep accurate medical
record documentation of a victim's statements, injuries,
symptoms, treatments, and referrals, including providing and/or
arranging for appropriate evidence collection and retention, and
taking or arranging for appropriate photographs to be taken of a
victim's injuries.
The medical record is a legal document and, as such, is maintained for a period of six years in New York State or three years past the age of majority (age 18). Documentation and photographs in the medical record are very important since they can be used as evidence of assault, particularly in legal proceedings. For example, medical records can be subpoenaed into court should another incident occur or if the patient decides to divorce and/or seek child custody or support. Victims of domestic violence should also be afforded appropriate evidence collection that follows recommendations set forth in the New York State Department of Health's Sexual Assault protocols.
Health care providers should not refrain from accurate and thorough medical record documentation out of concern that the patient might lose insurance coverage because she is a victim of domestic violence. In New York State, Chapter 174 of the Laws of 1996 prohibits insurance companies and health maintenance organizations from discriminating against domestic violence victims. Specifically, Chapter 174 outlaws designating domestic violence as a preexisting condition and denying or canceling an insurance policy or requiring a higher premium or payment when the insured is/has been a domestic violence victim.
- Strategies should be developed that ensure
confidentiality in cases in which a provider/facility is treating
both the abuser and the victim.
In cases where a health care provider or facility is treating both the victim and the abuser, ensuring that confidentiality procedures are strictly followed becomes even more critical. To this end, it is crucial that the victim and abuser be seen separately. Victim information should be kept strictly confidential and should not be disclosed to the patient who is the abuser without the express written consent of the victim.
- Managed Care Organizations should ensure that their
plans provide for coverage/reimbursement of emergency department
visits by victims of domestic violence who may seek emergency
care or shelter from an impending domestic violence
assault.
While primary care settings are important for early identification and referral of domestic violence victims, they are generally not accessible 24 hours a day or on short or no notice. As a result, victims of domestic violence may seek refuge from an impending assault by accessing emergency department services. Many times, emergency departments may be best equipped to deal with victims in immediate crisis. Hospital emergency departments may have an established working relationship with local police and/or district attorney's office should the patient decide to pursue a criminal justice response to her victimization, and they are the prime providers of evidence collection in most communities.
In fact, Managed Care Organizations may be legally required to reimburse patients for emergency care delivered under the above described circumstances based on Article 49 of the NYS Managed Care Omnibus Bill of 1996.
- Private, routine screening for domestic violence
should be conducted with all female patients to determine if they
are being abused by their intimate partners.
- ABUSER ACCOUNTABILITY
- As employers, health care facilities that have
knowledge of a physician, physician's assistant, or
specialist assistant who has been convicted of any domestic
violence crime should ensure that a report is generated from the
District Attorney's office to the New York State Department
of Health's Office of Professional Medical
Conduct.
- As employers, health care facilities that have
knowledge of a licensed health care professional (other than a
physician, physician's assistant, or specialist assistant)
who has been convicted of any domestic violence-related crime
should file a report with the New York State Education
Department's Office of Professional Discipline.
- In the case of a victim's partner coming on-site,
providers should activate appropriate in-house security measures.
If the abuser refuses to leave, and/or engages in acts that
threaten the safety of staff or patients and/or that violate an
existing order of protection, the police should be called. Health
care providers should consider the input of the victim in
developing a response plan but also maintain a responsibility to
respond quickly to the safety-related needs of staff and other
patients.
- As employers, health care facilities that have
knowledge of a physician, physician's assistant, or
specialist assistant who has been convicted of any domestic
violence crime should ensure that a report is generated from the
District Attorney's office to the New York State Department
of Health's Office of Professional Medical
Conduct.
- SYSTEMS' RESPONSIBILITY
- Staff of hospitals and diagnostic and treatment
centers must receive education in the identification and
treatment of victims of domestic violence. All other health care
providers and health care facility administrators should receive
training and education on domestic violence and appropriate
treatment and response within the health care system.
New York State Department of Health Regulatory Code 751.6 requires that all hospital staff receive education in the identification and treatment of victims of domestic violence. The Joint Commission on Accreditation of Health Organization (JCAHO), under PE.1.8, requires staff of hospitals, and diagnostic and treatment staff to be trained in identifying and assessing possible victims of abuse.
Although not required, all health care providers should be trained on domestic violence. The training should include an understanding of the dynamics of domestic violence, assessment tools, appropriate interview and intervention skills, and an adequate knowledge of domestic violence resources in the community, as outlined in the Guiding Principles, 3.a. In addition, health care providers should receive training on relevant state laws and regulations, their organization's domestic violence protocol and job-specific duties, the health consequences of domestic violence, identification of clinical indicators, basic safety planning, medical record documentation, and how to make appropriate referrals. Training should be comprehensive and ongoing.
- With the appropriate releases of information, health
care providers should coordinate a victim's care both
internally and externally with other systems the victim may be
involved with including domestic violence services, mental
health, substance abuse, law enforcement, etc.
Case management and coordination is key to the success of victims in developing and implementing effective safety plans. Health care facility administrators and directors should develop and support efforts that facilitate coordination of services for victims.
- Hospitals, diagnostic and treatment centers, and
emergency services must develop and implement written
polices and procedures for identifying and treating domestic
violence. All other health care facilities, provider
organizations, health care delivery systems and subsystems should
also develop, implement, and regularly update comprehensive
written policies, protocols, and standards of care that outline
an effective response to domestic violence victims.
The New York State Department of Health Regulatory Code 751.5 requires hospitals and Diagnostic and Treatment Centers to develop and implement written policies and procedures on the identification and treatment of domestic violence. Section 405.9 requires emergency services to develop and implement policies and procedures"which provide for the management of cases of suspected or confirmed domestic violence victims."While not required by Regulatory Codes, other health care facilities, provider organizations, and health care delivery systems should also develop and implement such policies and procedures.
To the fullest extent possible, such policies/protocols should be developed in consultation with local domestic violence service providers. Such policies and protocols should be developed with active participation of the line staff and others who will be responsible for day-to-day implementation.
- Health care facilities should develop ongoing
mechanisms to maintain/ improve the system's
response.
Examples of this are inclusion of domestic violence education into all ongoing in-service education programs, orientation programs for new staff, inclusion of domestic violence identification and response into Continuous Quality Improvement (CQI) systems, and the establishment of case management teams.
- Health care facilities should develop mechanisms to
hold staff accountable for performing their duties in a manner
consistent with the facility's protocol.
Administrators and supervisors should create incentives for good performance and provide clearly articulated sanctions for staff who fail to comply or who engage in actions which may further endanger victims/patients. Administration should publicly demonstrate a commitment to improve facility response to victims and should appoint a person, or preferably a team of persons, to act as liaison for the facility, participating in the coordination of training and implementation activities, attending interagency meetings and community coalitions or task forces. Administration should provide support for such appointed persons by ensuring that the appointed representative can attend to such duties during the performance of regularly scheduled work hours and by providing such person or persons necessary support to engage in the additional duties that such an appointment adds.
- Information on domestic violence as a public health
problem for women and children, including its correlation with
other significant public health problems, such as unintended
pregnancy, low-birth weight, infant mortality, low immunization
rates, HIV infection, sexually transmitted diseases, etc., should
be broadly disseminated throughout the county.
- Cross-training should be conducted between health care providers, domestic violence service providers, the child welfare system, mental health system, substance abuse treatment system, the police, and the courts. Written interagency protocols should be developed between the health care systems and these other systems.
- Staff of hospitals and diagnostic and treatment
centers must receive education in the identification and
treatment of victims of domestic violence. All other health care
providers and health care facility administrators should receive
training and education on domestic violence and appropriate
treatment and response within the health care system.
(22)"Domestic Violence Intervention Calls for More Than Just Treating Injuries."JAMA. August 22/29, 1990. Vol. 264, No. 8.
(23) Flitcraft, Anne, Evan Stark, Diana Zuckerman, Anne Grey, Judy Robinson, and William Frasier."Wife Abuse in the Medical Setting: An Introduction for Health Personnel."Monograph 7, Washington, D.C., Office of Domestic Violence.
