IPV Screening? Critical Review of IPV Screening toolsReview the City Health Information (CHI) brochure from NYC Dept of Health and the USPSTF recommendation on IPV (both

Volume 36 (2017) The New York City Department of Health and Mental Hygiene No. 2; 9-16

City Health Information IntImate Partner VIolence: encouragIng DIsclosure

anD referral In the PrImary care settIng • Intimate partner violence (IPV) is often an invisible concern that can seriously threaten health and safety. • Consider screening patients with the 4-question Abuse Assessment Screen o at initial or routine visits, o when a patient discusses a new relationship, o when a patient presents with trauma or concerning symptoms, o at prenatal and immediate postpartum visits (for female patients). • Encourage disclosure of IPV through culturally sensitive inquiry and routine dialogue. • If abuse is disclosed, validate patient experiences, provide a safety and clinical assessment, and document

findings thoroughly. • Promptly refer all patients who disclose IPV to appropriate services.

Intimate partner violence (IPV) is a pattern of coercion or violence used to establish and maintain power and control over a partner. IPV can encompass physical, sexual, psychological, and economic abuse by a current or former partner and can have lifelong impacts on mental and physical health.1-8

In New York City, 284,000 adults (4.3%) report ever fearing an intimate partner,9 and 10% of public high school students reported physical violence in their dating relationships in the past year.10 While IPV occurs in all demographic groups, the highest rates are reported in women, especially during pregnancy,11 and in people aged 18 to 24 years.12 People of color, sexual minorities, immigrants, people with low income, and those with physical disabilities are also at elevated risk (Box 1).2,10,12,13

IPV tends to escalate over time, often beginning with controlling tactics and verbal abuse.8,14 People often experience their first episode of IPV in adolescence, making early intervention key.14

INSIDE THIS ISSUE (Click to access)

INTRODUCTION IPV: At-risk populations (box)

IDENTIFY IPV Clinical indicators potentially consistent with IPV (box) Assault injuries consistent with IPV (box) Abuse Assessment Screen (box) When not to screen for IPV (box)

FOR PATIENTS WHO ANSWER “YES” TO ANY SCREENING QUESTION Safety and clinical assessment of patients disclosing IPV (box) Example of an injury location chart (body map) (figure)

FOR PATIENTS WHO ANSWER “NO” TO EACH SCREENING QUESTION

REFERRALS AND FOLLOW-UP FOR PATIENTS WHO DISCLOSE IPV

REPORTING AND OTHER REQUIREMENTS IPV, child abuse, and reporting (box) Circumstances in which IPV must be reported (box)

SUMMARY Medical documentation as evidence for housing assistance (box) IPV: clinical scenarios (box)

RESOURCES FOR PROVIDERS

RESOURCES FOR PATIENTS

REFERENCES

10 City HealtH information Vol. 36 (2017)

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BOX 1. IPV: AT-RISK POPULATIONS2,10,12,13

• Females, especially during pregnancy • Individuals aged 18-24 years • People of color • Immigrants • People living with limited income • Sexual minorities (gay, lesbian, bisexual, transgender,

gender nonconforming) • People with physical disabilities

Primary care and family physicians can identify IPV and provide victims and their families with needed care and referrals.15

• Consider screening patients with the 4-question Abuse Assessment Screen.

• Normalize discussions about IPV in your practice and encourage disclosure.

• Provide a full clinical assessment if abuse is suspected or disclosed.

• Refer all patients who disclose IPV to appropriate services.

IDENTIFY IPV Screening for IPV increases disclosure and facilitates referral.16,20,21

Consider screening for IPV • at initial or routine visits, • when patients discuss a new intimate relationship, • at prenatal and immediate postpartum visits, and • when a patient presents with trauma or concerning

symptoms (Boxes 26,7,11,16-19 and 37,18,22-24). Be alert to aspects of patients’ histories or symptoms that

could suggest IPV and follow up with specific questions.25 Normalize an inquiry about IPV by placing IPV-related

posters and pamphlets in patient areas. Include IPV in history- taking with leading statements or questions such as:

• “Since violence is so common in many people’s lives and because help is available for people being abused, I now ask every patient about it” or

• “Do you feel safe and comfortable at home?”

BOX 2. CLINICAL INDICATORS POTENTIALLY CONSISTENT WITH IPVa,6,7,11,16-19

General physical findings • Complaints of headache (including migraine), back pain,

chronic neck pain, vague complaints, and psychogenic pain • Digestive problems • Appetite disturbance, significant weight gain or loss • Assault injuries consistent with IPV (Box 3)

Obstetric and gynecologic findings • Painful intercourse and/or sexual dysfunction • Injuries during pregnancy, fetal injury, or poor birth

outcomes (eg, preterm delivery, low birthweight, miscarriage)

• Sexually transmitted infections, including HIV; signs/ symptoms of infection such as vaginal pain, itching, or discharge

• Urinary tract infection, pain on urination

Mental health findings • Symptoms of depression, anxiety, posttraumatic stress

disorder, insomnia • Inappropriate affect (eg, lack of expressiveness, minimal

eye contact) • Eating disorders (eg, anorexia, bulimia) • Frequent use of prescribed anxiolytics or pain medication • Abuse or misuse of drugs, alcohol, or tobacco • Suicidal or homicidal ideation or attempts aOne or more of these findings may be present.

BOX 3. ASSAULT INJURIES CONSISTENT WITH IPV7,18,22-24

• Patterned injuries (eg, to both wrists) • Multiple or frequent bruises, scrapes, or cuts in various

stages of healing • Sprains or fractures, dental trauma, facial fractures, or

spiral wrist fractures • Burns (cigarette, rope) • Wounds (gunshot, stab) • Localized hair loss and scalp injury • Detached retina, perforated eardrum • Concussion, subdural hematoma, or cerebral bleeding

associated with bruising to neck and back of head (from choking or head banging)

• Signs of sexual assault, such as injuries to genitalia and breasts

BOX 4. ABUSE ASSESSMENT SCREENa,26 1. Have you ever been emotionally or physically abused by a

partner? If so, by whom?

2. Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt? If so, by whom?

3. Within the past year, have you been forced to have sex against your will? If so, by whom?

4. Are you afraid of your partner?

If a patient answers YES to one or more questions, conduct a safety and clinical assessment (Box 6) and offer referral(s) for various types of assistance (Resources for Patients). aAdapted from American Medical Association. Abuse Assessment Screen. This and other IPV screening tools in English and Spanish for specific populations are available at Intimate Partner Violence and Sexual Violence Victimization Instruments for Use in Healthcare Settings: Version 1: www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf.

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BOX 5. WHEN NOT TO SCREEN FOR IPV22 Do not screen or assess when • there is no way to conduct the screening in private, • there are concerns that screening the patient would put

the patient or provider at risk, • there is a language barrier and you cannot secure an

interpreter. If you cannot screen but you suspect that the patient is experiencing IPV, note in the patient’s chart that the inquiry was not completed and schedule a follow-up appointment or referral to another provider.

Screen Screen using an effective standardized tool such as the

4-question Abuse Assessment Screen (Box 426). Under certain circumstances, screening should not be

conducted (Box 522).

Encourage disclosure To encourage disclosure: • Talk to the patient privately, without the partner, friends,

relatives, or children aged 3 or older present. • Ask questions clearly and directly, using nonjudgmental

words, tone, and body language. • If language is an obstacle, find a trained interpreter.

FOR PATIENTS WHO ANSWER “YES” TO ANY SCREENING QUESTION Conduct a full safety and clinical assessment (Box 622)

• If the patient is in immediate danger and, if necessary and the patient is willing, help him or her call the police or the NYC 24-hour Domestic Violence Hotline at 800-621-HOPE (or call 311 and ask for the Domestic Violence Hotline).

• Document location and severity of old and new wounds on an injury location chart, or “body map” (Figure27).

• Carefully document clinical findings and patient disclosure. The medical record may be used during medical/legal proceedings or be required to obtain social services.

• Avoid judgmental language. For example, use “patient states” rather than “patient alleges.”

Communicate your desire to help • Acknowledge the patient’s admission of abuse, thank them

for trusting you, and express concern about their safety. • Ask whether the patient would like to be connected to

NYC’s Family Justice Centers (Resources for Patients) for services such as legal assistance, counseling, and shelter.

• Provide a copy of the Victim’s Rights Notice (in Spanish). • Encourage those who feel unsafe around their partner to call

911 if in immediate danger; otherwise, call 800-621-HOPE or 311 and ask for the Domestic Violence Hotline. For some patients, acceptance and taking action may take time.

• Determine whether child protective services are required (Box 7).

• Screen the patient for coexisting depression and substance abuse (Resources for Providers).

• Use caution in prescribing sedatives that may diminish patients’ ability to defend themselves or de-escalate tensions.25

• Share additional resources (Resources for Patients).

BOX 6. SAFETY AND CLINICAL ASSESSMENT OF PATIENTS DISCLOSING IPV22

Safety assessment • Evaluate severity: “Are you in immediate danger? Are you

afraid to go home?” • Assess for escalation: “Has the violence gotten worse or

is it getting scarier?” • Assess for type of violence: “Does your partner ever try

to choke you and/or stalk or cyberstalk you?” • Listen for threats of homicide, suicide, or weapon use. • Identify whether the patient has somewhere safe to go.

General history Ask about: • Abuse in childhood or IPV in a previous relationship. • Child abuse in current family. • Lack of money and/or documents (eg, passports, visa). • History of miscarriage.

History of physical trauma • Take a history of physical injuries (include dates, times,

locales, and circumstances). • Note if there is an unexplained delay between the

occurrences of the injuries and medical treatment. • Determine if injuries are consistent with the given

explanation. • Use direct quotes whenever possible to identify the abuser

and describe the assault circumstances.

Mental health assessment • Screen for depression and anxiety. • Ask about alcohol and substance use; assess for misuse. • Assess for suicidal ideation. See Resources for Providers.

Physical examination • Examine for scars, injuries, or any other findings consistent

with trauma. • If patient reports recent sexual abuse, refer him or her to

rape crisis services and to appropriate ED care for a Sexual Assault Forensic Exam (SAFE). The patient must provide written consent for the SAFE forensic specimen collection (see Referrals and Follow-up, page 13).

• Use body maps to note old and new wounds and to document severity (Figure).

• Offer the option to be photographed (written consent recommended). Photographs can be important evidence for future legal actions to protect the victim.

12 City HealtH information Vol. 36 (2017)

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FIGURE. EXAMPLE OF AN INJURY LOCATION CHART (BODY MAP)27

ANATOMICAL DIAGRAMS-SKIN SURFACE ASSESSMENT Utilize diagrams to document all injuries and findings, including cuts, lacerations, bruises, abrasions, redness, swelling, bites, burns, scars and stains/foreign material on patient’s body. Distinguish pre-existing injuries from those resulting from the incident. Record size, color and appearance of all injuries. If an Alternate Light Source is used to assist in visualizing secretions, denote areas of (+)findings with “+ALS”.

L RR L

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FOR PATIENTS WHO ANSWER “NO” TO EACH SCREENING QUESTION

If you suspect current or past IPV despite a lack of patient disclosure:

• Respect the patient’s wishes and explain that you are available should the situation change.

• Document that a screening was conducted and that the patient did not disclose abuse.

• Include the reasons for concern in the medical record (eg, “physical findings not congruent with history or description” or “patient presents with evidence consistent with violence”).

• Document all the dates and times you see injuries on the patient at future visits.

• Offer information and resources (“If you should ever experience something like this…”).

• Provide a copy of the Victim’s Rights Notice (in Spanish). • Assess again at a later visit if circumstances allow.

REFERRALS AND FOLLOW-UP FOR PATIENTS WHO DISCLOSE IPV

When patients disclose IPV, refer them to appropriate services: • Refer to supportive social, legal, and mental health services,

safe shelters or transitional housing, and employment assistance28 (Resources for Patients).

• With patient consent, assist in linking to appropriate community services such as the New York City Domestic Violence Hotline (800-621-HOPE/800-HOPE-4673) and the Family Justice Centers.

• Refer patients to organizations that address their unique needs (eg, language other than English, issues pertaining to LGBTQ individuals) (Resources for Patients).

• Refer patients who report experiencing sexual violence within the past 96 hours to the nearest Emergency Department with specialized services for sexual violence victims for a Sexual Assault Forensic Exam (SAFE), rape crisis counseling services, and comprehensive medical, forensic, and psychosocial care (Resources for Patients).

• Provide information about rape crisis services to patients who disclose sexual violence that occurred more than 96 hours ago (Resources for Patients).

During subsequent patient visits, communicate ongoing concern, ask about resources the patient may have accessed, and assess whether the violence has continued or intensified. Potential follow-up questions include:

• “What services are helping you, such as counseling, a support group, or other assistance?”

• “Whom have you talked with, such as a family member or a friend, about the abuse?”

• “Is the abuse happening more often?” “Has the abuse worsened?”

If the patient is still not ready to act, remind him or her about the options (eg, individual safety planning, talking with friends or family, advocacy services and support groups, transitional/ temporary housing), and ensure that the patient has access to appropriate health care.

REPORTING AND OTHER REQUIREMENTS According to New York State law, you must report certain

injuries whether or not a patient elects to file a report (Box 8).29,30

Child abuse and maltreatment and IPV often coexist.31-33 Data suggest that between 30% and 60% of families experience both IPV and child abuse. An estimated 40% of child abuse victims experience violence between their parents.34 If child abuse or suspected abuse by a parent, guardian, or caregiver is identified when caring for a patient who discloses IPV, you must report this abuse (Box 7).

NYS law also requires hospitals and diagnostic and treatment centers to privately and confidentially provide copies of the Victim’s Rights Notice (in Spanish) to all suspected or confirmed adult IPV patients.35Additionally, facilities that serve maternity and prenatal patients are required to distribute copies of Are You and Your Baby Safe? (in Spanish).35

BOX 7. IPV, CHILD ABUSE, AND REPORTING You must report IPV-related abuse or suspected abuse of a child by a parent, guardian, or caregiver to child welfare authorities:

• If a child is in immediate danger, call 911.

• Within 48 hours of patient visit, report to the New York Statewide Central Register of Child Abuse and Maltreatment (SCR) at 800-342-3720 or, in NYC, call 311.

NYC 24-HOUR DOMESTIC VIOLENCE HOTLINE

800-621-HOPE or call 311 and ask for the Domestic Violence Hotline.

BOX 8. CIRCUMSTANCES IN WHICH IPV MUST BE REPORTED29,30

Type of Injury or Abuse Action

• Firearm injury • Potentially life-threatening

injury inflicted by a knife or other sharp object

• Immediately report to the local police or call 911.

• Any burn that may result in death (second- or third- degree burns to more than 5% of the body)

• Any burns to the upper respiratory tract

• Laryngeal edema due to inhalation of superheated air

• Within 72 hours of patient visit, complete and e-mail the Burn Injury Report form or

• Fax the completed form to 800-345-5811.

Inform the patient that the injury will be reported as state law requires.

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1. Adira is 26 years old and in the second trimester of pregnancy. She made an appointment at a prenatal clinic because she has had a headache for 3 days and is experiencing dizziness and difficulty balancing. Adira appears withdrawn and agitated. She speaks little English and her boyfriend says he will translate for her.

What might suggest that Adira is a victim of IPV? A. Headache B. Pregnancy C. Inappropriate affect D. Boyfriend’s presence as translator E. All of the above

2. Adira’s provider explains that it is standard for patients to be examined alone and secures a translator. The boyfriend leaves; the provider asks if everything is okay, then administers an IPV screen. Adira remains uncommunicative and responds “no” to all screening questions.

The provider should do all EXCEPT A. Document that a screening was conducted and

that the patient did not disclose abuse. B. Communicate that the clinic is a safe place for

immigrants. C. Assess again at a later visit. D. Ask Adira about her legal status. E. Offer information and resources.

3. Ricky, a 43-year-old man who suffers from depression, presents with shortness of breath and pain in his back and ribs. During the exam, Ricky taps his foot and nervously looks at the door. When asked about symptom onset, Ricky jokingly says that he and his wife often fight about finances and chores. He chuckles and says that he’s good at ducking missiles, but she finally got him.

The provider should do all EXCEPT A. Listen carefully to Ricky and validate his experience. B. Ask Ricky whether he feels safe and whether he thinks

his children are safe. C. Carefully document clinical findings and Ricky’s

disclosure, in his own words. D. Refer Ricky to appropriate local services. E. Report the violence to law enforcement.

IPV: CLINICAL SCENARIOS

Answers: 1 – E; 2 – D; 3 – E

MEDICAL DOCUMENTATION AS EVIDENCE FOR HOUSING ASSISTANCE

The New York City Housing Authority (NYCHA) allows medical documentation of IPV as evidence

for women and men applying to move into, or transfer within, the public housing system.

For more information, call 800-621-HOPE (4673), or call 311 and ask for the 24-hour

NYC Domestic Violence Hotline.

SUMMARY IPV can seriously threaten the health and safety of

patients and their families. Normalize screening during regular patient visits, validate patient experiences, and provide a safety and clinical assessment of consenting patients, carefully documenting findings. Promptly refer all patients who disclose IPV to appropriate, culturally sensitive services. Maintain a dialogue with both IPV victims and patients who hesitate to disclose IPV.

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RESOURCES FOR PROVIDERS General Information and Resources • NYC Health Department: o Domestic Violence: Resources for Health Care Providers:

www1.nyc.gov/site/doh/health/health-topics/domestic- violence-provider-resources.page

o Intimate Partner Violence (IPV): www1.nyc.gov/site/doh/ providers/resources/public-health-action-kits-ipv.page

• NYC Health and Hospitals Corporation: Sexual Assault Response Teams: www1.nyc.gov/html/hhc///html/about/ About-HospServices-OurServices-SexualAssaultTeam.shtml

Legal Information • New York State Office for the Prevention of Domestic Violence: o Summary of laws, regulations and guidelines related to

domestic violence and the health care system: www.opdv.ny.gov/professionals/health/laws.html

o Victim’s Rights Notice (in English and Spanish): www.opdv.ny.gov/professionals/criminal_justice/police/ vrnoticeeng.html

www.opdv.ny.gov/professionals/criminal_justice/police/ vrnoticespan.html

o Burn Injury Report form: www.dhses.ny.gov/ofpc/ documents/forms/burn-injury-report.pdf

Child Protective Services • NY State Central Register (SCR) Child Abuse & Maltreatment

24/7 Hotline (or call 311): o General Public: 800-342-3720 o Mandated Reporters: 800-635-1522 o Deaf/Hard of Hearing: 800-638-5163

System-level Tools • AHRQ Innovations Solutions profile of Kaiser Permanente’s

Northern California’s Family Violence Prevention Program: innovations.ahrq.gov/profiles/family-violence-prevention- program-significantly-improves-ability-identify-and-facilitate

Mental Health and Substance Abuse Management • NYC Well: providers can call for assistance referring

patients to behavioral health services: 1-888-NYC-WELL (1-888-692-9355); nycwell.cityofnewyork.us/en/

• Integrating behavioral health into primary care o Mental Health Service Corps: fully funded behavioral health

practitioners trained to deliver behavioral health screenings and interventions in primary care settings: www.hunter.cuny.edu/mental-health-services-corps/about

Downloadable Patient Education Materials • New York City Family Justice Centers: www.nyc.gov/html/

ocdv/downloads/pdf/Materials_FJC_OnePage_English.pdf • Health Bulletin. Intimate Partner Violence: www1.nyc.gov/

assets/doh/downloads/pdf/public/dohmhnews7-07.pdf • Are You and Your Baby Safe? (in English and Spanish):

www.health.ny.gov/publications/4605 • Share Your Story: Because you have the right to be healthy

and safe: opdv.ny.gov/professionals/health/sharecard.html

City Health Information Archives: www1.nyc.gov/site/doh/ providers/resources/city-health-information-chi.page (scroll down and click on City Health Information Archives)

RESOURCES FOR PATIENTS For Anonymous, Confidential Help 24/7, Call • New York City Domestic Violence Hotline: 800-621-HOPE

(4673) (or call 311 and ask for the Domestic Violence Hotline; [TTY] if hearing impaired: 866-604-5350), or

• New York State Coalition Against Domestic Violence (English/ Spanish/multilanguage accessibility): 800-942-6906 or 711 for the deaf or hard of hearing

• New York City Rape and Sexual Assault Hotline: 212-227-3000 (or call 311 and ask for the Rape and Sexual Assault Hotline)

• NYC Well provides a confidential connection in more than 200 languages to crisis counselors and mental health referral services via:

o Text WELL to 65173 o Chat: nycwell.cityofnewyork.us/en/ o Phone: 1-888-NYC-WELL (1-888-692-9355)

General Information and Services • NYC Health Department Domestic Violence Page:

www1.nyc.gov/site/doh/health/health-topics/domestic- violence.page

• NYC Mayor’s Office to Combat Domestic Violence: www1.nyc.gov/site/ocdv/get-help/get-help.page

• NYC Services Snapshot: www.nyc.gov/html/ocdv/html/help/snapshot.shtml

• Family Justice Centers, New York City Office to Combat Domestic Violence: www1.nyc.gov/site/ocdv/programs/ family-justice-centers.page

• New York State Office for the Prevention of Domestic Violence: opdv.ny.gov/help/fss/contents.html

Special Populations • Parents and children: Prevent Child Abuse New York:

800-CHILDREN (244-5373) or www.preventchildabuseny.org • Teens: DayOne: www.dayoneny.org/ • LGBTQ: The New York City Anti-Violence Project: www.avp.org/ • Seniors: New York City Department for the Aging:

www.nyc.gov/html/dfta/html/services/crime-victims.shtml If a senior is in immediate physical danger, call 911 (if hearing

impaired, call 24-hour hotline: (TTY) 800-810-7444.) Otherwise, call 311 and ask to report elder abuse.

• People with disabilities: Barrier-Free Living (counseling, support, shelter) Hotline: 800-799-7233/800-787-3224 (TTY), or call 212-533-4358 or visit www.bflnyc.org

• The hearing impaired: Abused Deaf Women’s Advocacy Services: www.adwas.org/. National hotline: 855-812-1001 weekdays or [email protected]

• Victims, their children and pets: 800-621-4673 or urinyc.org/ program/domestic-violence

• Mental health concerns: Confidential support, 24 hours a day, in multiple languages is available at nycwell.cityofnewyork.us/en/

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