A SYSTEMS-MODEL APPROACH Improving IPV services in a large health care organization Academy on Violence and Abuse April 15, 2011 Brigid M cCaw, MD Medical Director, Family Violence Prevention Program Kaiser Permanente Northern California Krista Kotz, PhD, MPH Program Director, Family Violence Prevention Program Kaiser Permanente Northern California

2001 Institute of Medicine Report Confronting Chronic Neglect

 Health care has critical role in identification, intervention and prevention of IPV  But, professional recommendations, practice guidelines and traditional clinician education are not enough to change behavior  Kaiser Permanente noted as “demonstrating success with the use of systems-change models in a health care organization”

Kaiser Permanente (KP)

 Largest, non-profit health plan in United States  Founded in 1945  8.6 million members nationally  serves 9 states and District of Columbia  15,130 doctors; 164,000 employees  KP, Northern California  3.4 million members  4000+ doctors,  55,000 employees  14 hospitals, 35 health care offices

What does KP bring to this issue?

    Integrated system of care  primary care and specialty care  mental health services  emergency services and hospitalization Extensive experience in chronic condition management, electronic health record, medical education, research Commitment to Prevention Social Mission

“Systems-Model” approach

Inquiry & Referral On-Site DV Services Supportive Environment Leadership and Quality Improvement Community Linkages

P A C I F I C O C E A N

1998 KP NCal DV Prevention Teams

NORTHERN CALIFORNIA

P A C I F I C O C E A N

2010 KP NCal DV Prevention Teams

NORTHERN CALIFORNIA

2010 – every KP region is using “systems-model” to improve IPV services

Group Health Northwest Northern California Southern California Colorado Ohio Mid-Atlantic Georgia Hawaii

“Systems-Model” approach

Inquiry & Referral On-Site DV Services Supportive Environment Leadership and Quality Improvement Community Linkages

Supportive Environment

What is it?

    Information: restrooms, exam rooms, on-line, podcasts, health ed classes Posters: “Let us know, we can help” Reaching patients everywhere they contact the health care system Engaged and informed workforce

Supportive Environment IPV information and resources for adults and teens

Patient brochure Resource sheets Teen dating violence brochure

Supportive Environment Information for Employees

Employee brochure Online training for managers

Supportive Environment Stories of courage, survival and hope

kp.org/domesticviolence

Community Linkages

What are they?

 24-hour crisis response line  Emergency shelter  Transitional housing  Counseling  Legal services

On-site IPV Response



Social Services



Mental Health

 Triage for other mental health conditions  Danger assessment  Safety plan  Support groups  Referral to community resources

Inquiry and Referral

    

Role of the clinician is clear and limited

ASK AFFIRM ASSESS DOCUMENT REFER

Making the right thing easier to do

Inquiry and Referral Multiple types of training

      Lecture presentations (CME) Brief departmental updates Case presentations Online skill-building training Video clips demonstrating documentation Reports on quality improvement data

Inquiry and Referral Using technology to improve care



Supporting clinicians:

 Tools in electronic medical record  Online clinician training  Point-of-care online resources 

Engaging patients:

 Online information for patients  Advice and Appointment Call Center

Implementation – how it’s done Each medical center has Physician Champion and multi-disciplinary committee that:

 meets regularly   implements the “Systems-model” in phases reviews quality measures and develops annual goals

All medical center committees meet twice yearly for:

 leadership development     sharing best practices updates on research review of quality metrics developing goals and strategy

IPV Quality Measures Qualitative measures



Each medical center has:

   Physician champion for IPV Multi-disciplinary team to implement the model Protocol for referral to mental health

IPV Quality Measures Quantitative measures



IPV identification



Mental health follow-up among those newly identified

IPV Quality Measures Why measure IPV identification rather than screening rates?

Identification continues to improve Most identification in mental health and primary care 3000 6,173 2000 ED/Urgent Care Mental Health Primary Care 1000 1,022 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

IPV Quality Data: focus on women age 18-65 Why focus on this group?

Women age 18-65 are at highest risk for IPV

IPV identification rate among women age 18-65 Medical Center

Medical Center A Medical Center B Medical Center C Medical Center D

Women Members Ages 18 - 65

15,486 16,420 28,796 8,134

Women Experiencing IPV Denominator

619 657 1,152 325

Women Diagnosed with IPV Numerator

288 219 295 82

IPV Identification Rate Rate (%)

46% 33% 26% 25%

IPV identification rate – by Departments We assess IPV identification rates for: Medicine, OBGyn, ED, Psychiatry Medical Center

Medical Center A Medical Center B Medical Center C Medical Center D

Women Members Ages 18 - 65 Who Visited Medicine Dept Women Experiencing IPV

2150 1603 676 2988

Denominator

946 705 297 1,315

Women Diagnosed with IPV Numerator

195 139 46 181

IPV Identification Rate Among Women Who Visited Medicine Dept Rate (%)

21% 20% 15% 14%

Reports are sent via email to clinic teams and to Chiefs groups and other leadership groups Key messages Data reports

IPV quality measures used to drive change Women's Health Dashboard 2010 Outpatient and Inpatient Quality Metrics

1 2 3 4 5

Women's Health Dashboard: Medical Center Report Outpatient and Inpatient Quality Metrics

MEETS TARGET

BELOW TARGET

Reporting Date

Breast Cancer Screening Dec 2010 Cervical Cancer Screening Dec 2010 Chlamydia Screening Dec 2010 Post-Partum Visit Rate Nov 2010 PreNatal Entry Nov 2010

6

2010QTR4

7 8

MIGYN Intimate Partner Violence (IPV) Dec 2010 2nd Generation Ablations in Clinic Dec 2010 Essure and HSG Follow-up June 2010 Closed Hysterectomy & Mini-Lap Dec 2010

Study Period

Previous 24 months Previous 36 months Previous 12 Months 11/06/2009 11/05/2010 11/06/2009 11/05/2010 01/01/2009 12/31/2010 01/01/2010 12/31/2010 04/01/2010 - 06/30/2010 01/01/2010 12/31/2010 HYSTPROPH HYSTDISC

Medical Center A Medical Center B Medical Center C Medical Center D

What is associated with improved performance at individual medical centers or departments?

   

Chief support Brief, frequent IPV presentations at dept mtgs Brief online trainings Easily accessible mental health follow-up

Violence prevention website Link on electronic medical record “homepage” Easy for clinicians to access

Brief trainings Carepath

What helps drive the program forward?

 Research partnerships  Evaluation data from pilot site  Executive sponsorship  Availability of IPV services for workforce

Consistent learnings from implementation of IPV services and “scaling up”

      Road map that is easy to understand and readily customized to resources on hand Avoid “re-inventing the wheel” – offer a portfolio of implementation tools Include “technology enablers” when possible Choose quality improvement measures that provide actionable information at local level Cultivate stories of success and look for promising practices Engage and provide resources for workforce

Long term sustainability requires alignment with other health care priorities

     Patient safety Quality and coordination of care Health care costs Patient satisfaction Reducing health care disparities

DV prevention is part of a strategic approach to both quality, service, and affordability

By doing the right thing, we can improve quality, increase service, satisfaction, and personal lives while also decreasing costs to employers and patients. It is important that all CEOs understand the imperative and that they see DV programs as a positive investment.

Comments by Dr. Robert Pearl, TPMG Executive Director CEO Roundtable on DV and the Workplace Sponsored by Fortune Magazine, 2007, New York City

Using the “Systems Model” in other health care settings and countries

Bilateral exchange of learnings

We believe in

THE STRENGTH

of healthy relationships

Contact Information Brigid M cCaw, MD Kaiser Permanente [email protected]

,

MS, MPH, FACP Medical Director, Family Violence Prevention Program Krista Kotz, PhD, MPH Program Director, Family Violence Prevention Program Kaiser Permanente [email protected]

kp.org/domesticviolence

References (1)

     “Developing a Health System Response to Intimate Partner Violence,” McCaw, B, and Kotz, K, Intimate Partner Violence: A Health-Based Perspective, C. Mitchell and D. Anglin ed., Oxford University Press 2009 AHRQ Innovations Solution: “ affected by domestic violence,” Family Violence Prevention Program significantly improves ability to identify and facilitate treatment for patients http://www.innovations.ahrq.gov/content.aspx?id=2343

AHRQ Tool for Assessment of Health System Response

http://www.ahrq.gov/research/domesticviol/ National Consensus Guidelines Identifying and Responding to Domestic Violence, Family Violence Prevention Fund 2004 “Intimate Partner Violence,” McCaw, B., A Provider’s Handbook on Culturally Competent Care: Women’s Health, Kaiser Permanente National Diversity Council and Office 2009

References (2)

     “Mental Health Service Referral and Utilization among Women Experiencing Intimate Partner Violence,” Ahmed A, McCaw B. Am J of Managed Care, 2010.

“Domestic Violence and Abuse, Health Status, and Social Functioning,” McCaw B, Golding B, Farley, M, Minkoff J. Women and Health, 45(2), 2007.

“Family Violence Prevention Program: Another Way to Save a Life,” McCaw B, Kotz K.The Permanente Journal 9(1), 2005.

“Women Referred for On-site Domestic Violence Services in a Managed Care Organization,” McCaw B, Bauer H, Berman W, Mooney L, Holmberg M, Hunkeler E. Women and Health, 35(2-3), 2002.

“Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting,” McCaw B, Berman B, Syme L, Hunkeler E. American Journal of Preventive Medicine, 21(3), 2001.

References (3)

    “The Science of Large Scale Change in Global Health,” McCannon C, Berwick D, Rashoud M. JAMA 298 (16), 2007.

“Disseminating Innovations in Health Care,” Berwick D.M., JAMA 289 (15), 2003. Real Collaboration: What It Takes for Global Health to Succeed, Rosenberg M. et al, UC Press 2010.

Switch: How to Change Things When Change is Hard, Heath C, Heath D, Crown 2010.