Addressing Intimate Partner Violence in Primary Care Practice

Leigh Kimberg, MD

Disclosures
In This Article

Post Screening: Assessment, Intervention, and Documentation

Obviously, screening without further assessment, intervention, and documentation is an inadequate response to screening. How follow-up to screening occurs, though, may vary widely in different primary care sites depending on the patient population being screened, the model of care, staffing patterns and responsibilities, and resources available to providers and patients. At some sites, screening and follow-up may be primarily the responsibility of the primary provider; in others, very little of the response to intimate partner violence may be the responsibility of the primary provider. Because of the emotional vulnerability of a patient who may be suffering from acute stress disorder or posttraumatic stress disorder, the long process of change in readiness to end an abusive relationship and efficiency concerns in practice, assessment, and intervention most often take place during multiple visits. In some practice settings, much of the assessment and intervention may be done through collaboration with community advocates and agencies. It is important that the entire response, from screening to follow-up and documentation, be institutionalized and fully incorporated into the primary care of the patient. Appropriate follow-up to screening should include the 3 following actions[30,106]:

Assessment. The primary provider or other members of a multidisciplinary team should take further history about the intimate partner violence with particular attention to the immediate risk of homicide or injury (including the perpetrator's use of and access to weapons), suicidal ideation or plan, degree of readiness for change, and safety of children (after explaining limits of confidentiality). Assessment also includes a physical examination if the patient reports an acute violent event.

Intervention. Intervention has 4 major components:

Messages of support . Tell the patient that she/he does not deserve to be threatened, hurt, or treated badly and that there is no excuse for violence and abuse under any circumstances. Explain that the violence is not the victim's/survivor's fault.

Education. Let the patient know that she is not alone and that intimate partner violence affects millions of women every year, from every social, economic, racial, and religious background. If children are involved, explain how intimate partner violence adversely affects children.

Safety planning . Assist the patient in safety planning or refer the patient to appropriate on-site or community agencies that can help her with safety planning. Make sure the primary care provider/practice knows a safe way to contact the patient. If referring the patient to an outside agency, it is helpful for staff to assist the patient in contacting the agency before leaving. Safety planning may involve calling the police if the patient desires police assistance.

Referrals. Refer the patient to community resources and give the patient a written list of these resources if she thinks it is safe to take with her. Make appropriate medical, psychiatric, advocacy, and legal referrals.

Documentation.

Complete, thorough, legible documentation of the history of abuse in the notes and drawings of any injuries is essential. The results of screening should be documented so all providers caring for the patient may be informed of this crucial health problem. Careful documentation may be used as evidence should the victim/survivor decide to attempt to prosecute the abuser.

For patients experiencing intimate partner violence, the assessment itself may become an empowering intervention. For example, one can point out strengths to a patient while gathering information: "What strength you must have to get through even one hour of one day of this kind of treatment by your partner. You are a strong person. No one deserves to be treated this way. It must be incredibly difficult to be alone in your suffering. We would like to give you more support." Involving a team of healthcare providers, mental health providers if indicated, community intimate partner violence advocates, legal assistance providers, and the police in assisting the victim/survivor, as the patient allows and desires, expands the circle of support for the patient.

Sometimes, for various reasons, patients will not feel safe enough or ready to reveal intimate partner violence even though the provider suspects abuse and asks them directly about it. For these patients, a "negative" answer to screening questions is still a successful intervention.[72,107] This patient will have heard at least once in her life that someone who cares about her health and well-being thinks this is an important concern. One can educate, support, and provide this patient with the opportunity for future assistance: "I ask all my patients about violence in their relationships because, unfortunately, it is very common. If that ever happens to you or a friend of yours, please tell them that this is a safe place to talk and get help." If one can anticipate the fears of a patient, one can sometimes enhance comfort with future disclosure. For example, to an undocumented immigrant patient, one could explain, "There is a federal law that allows people who are being abused by their husband to apply for citizenship without the husband's assistance.[108] If you or a friend of yours are ever hurt or threatened by your husband, we can help."

For those patients who are not victimized by intimate partner violence, we send messages to those who may be in a position to assist others that intimate partner violence is an important health problem. A negative response can be used to educate. "I ask all my patients about violence in their relationships because it is unfortunately very common." The provider personally models for her/his patients how to address intimate partner violence directly and privately. Perhaps these patients will advise a friend, family member, neighbor, or coworker that there is help available. By adopting a screening protocol and practice, one sends a message to the community that one supports the right of all people to respectful, nonviolent relationships.

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