Chapter 31 - Intimate Partner Violence

Part 3 - Professional Services

3-31.1  INTRODUCTION

1. Purpose.  To identify victims of Intimate Partner Violence (IPV) and intervene on their behalf within a system of medical care and referral that is patient-centered, culturally sensitive, and trauma-informed.
2. Scope.  This chapter establishes uniform clinical care guidelines on identifying and responding to IPV for all patients presenting to Indian Health Service (IHS) health care facilities.
3. Background.  IPV is a significant public health problem that can have devastating effects on individuals, families, and communities.  American Indian and Alaska Native (AI/AN) people experience rape, physical violence, and/or stalking by an intimate partner at higher rates than the general U.S. population.  However the impact of IPV is not fully understood as social barriers such as privacy, guilt, shame, and fear inhibit reporting rates.

   IPV has been correlated with an increased risk of heart disease, asthma, chronic pain syndromes, gastrointestinal disorders, sexually transmitted infections, gynecological, and prenatal complications.  There are emotional and psychological consequences, such as depression, anxiety, eating disorders, and post-traumatic stress disorder.  Adverse health behaviors associated with IPV include high-risk sexual activity, alcohol and substance use/abuse, and increased risk for suicide.

   The highest rates of IPV occur in women of childbearing age, a time when early screening, detection, and intervention may increase personal safety.  The impact on children exposed to IPV has wide implications including increased risk for physical, sexual, emotional neglect, harm and death.

4. Authorities.
   1. Indian Law Enforcement Reform Act, 25 United States Code (U.S.C.) § 2801 et seq
   2. Indian Health Care Improvement Act, 25 U.S.C. § 1601 et seq
   3. Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd
   4. Privacy Act, 5 U.S.C. § 552a
   5. Freedom of Information Act, 5 U.S.C. § 552
   6. Drug Abuse Prevention, Treatment, and Rehabilitation Act, 21 U.S.C. § 1101
   7. Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act, 42 U.S.C. § 4541
   8. Administrative Simplification Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   9. Confidentiality of Medical Quality Assurance Records, 25 U.S.C. § 1675
   10. Patient Safety and Quality Improvement Act of 2005, 42 U.S.C. §§ 299b-21-26
5. Policy.  It is the policy of the IHS that:
   1. Agency personnel will follow IPV screening recommendations established by the US Preventive Services Task Force (USPSTF).  (Refer to Section 3-31.3);
   2. Patients who screen positive for IPV will receive intervention and referral, when appropriate;
   3. All patients who present to IHS health care facilities with a history of IPV have access to a forensic medical examination with evidence collection, when appropriate, and receive a danger and lethality assessment and safety plan;
   4. Patients requiring transfer offsite for services shall receive care in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd;
   5. Staff participate in a coordinated community response which may include healthcare, behavioral health, social services, victim advocates, law enforcement, traditional healers and faith based organizations; and
   6. Every facility shall develop site-specific policies and procedures to address IPV consistent with Chapter 31, IHM.
6. Definitions.
   1. Chain of Custody.  A process followed to preserve evidence, in order for evidence to be legally defensible and acceptable to courts and government agencies.  The process includes properly identifying evidence, arranging collection by a neutral party who has no personal interest in the test results (i.e. hospital, clinic, lab), sealing and securely holding evidence until released to the appropriate law enforcement or agency (including BIA, FBI, Tribal, and State).
   2. Danger and Lethality Risk Assessment.  Assesses the patient's potential level of danger of being injured or killed by an intimate partner, associated health problems, the history regarding extent and impact of abuse, information about the perpetrator and inquiry into suicidal and/or homicidal ideation.
   3. Evidence Collection Kit.  (Also known as the Sexual Assault Evidence Collection Kit).  A State-specific kit to collect forensic evidence, document assault history, body maps, biological sample collection, guidance for the examination, treatment, information, and referrals.  The kit is appropriate for forensic examination and documentation following IPV, whether or not sexual assault co-occurred.
   4. Intimate Partner.  A person with whom one has a close personal relationship that may be characterized by the partner's emotional connectedness, regular contact, ongoing physical contact and sexual behavior, identity as a couple, and familiarity and knowledge of each other's lives.  The relationship need not involve all of these dimensions, and sexual intimacy is not required.  Intimate partner relationships include current or former:
      1. spouses (married spouses, common-law spouses per State definition, civil union spouses, domestic partners)
      2. boyfriends/girlfriends
      3. dating partners
      4. ongoing sexual partners

      Intimate partners may or may not be cohabiting, and can be the opposite or the same sex.  If the victim and the perpetrator have a child in common, and a previous relationship but no current relationship, then by definition they fit into the category of former intimate partner.

   5. Intimate Partner Violence.  Physical, sexual, or psychological harm, including stalking, that is committed against a person by a current or former partner or spouse.  This type of violence can occur among heterosexual or same-sex couples, and does not require sexual intimacy.  Intimate Partner Violence (also called domestic violence, dating violence, relationship violence, spousal abuse, or battering) is a pattern of abusive behavior:  physical (e.g., striking, shoving, kicking, punching, strangling, restraining); sexual (rape, sexual assault); emotional (e.g., isolation from friends and family, verbal abuse); and psychological (e.g., threats of harm to partner or self, a third party, pets, or property; humiliation, degradation, and harassment) that is used by one person to gain power and control over a current or former spouse or intimate partner, or current or former dating partner, regardless of gender or sexual orientation.
   6. Intimate Partner Violence Examiner (IPVE).  A registered nurse, advance practice nurse, physician, or physician assistant who has been specially trained to perform IPV and sexual assault medical forensic examinations.
   7. Intimate Partner Violence Medical Forensic Examination.  An examination following IPV with or without sexual assault.  The examination includes obtaining consent for the exam and the medical history; performing the physical examination; coordinating treatment of injuries, documentation of biological and physical findings, and collection of evidence; documentation of findings; providing information, treatment prevention, and referrals for sexually transmitted infections (STIs) and pregnancy; referrals for suicidal ideation, alcohol and substance abuse, and non-acute medical concerns; and follow-up as indicated.
   8. Perpetrator.  An individual who inflicts violence or abuse, or causes the violence or abuse to be inflicted on the victim.
   9. Priority Treatment.  Refers to the immediate and more private care for IPV patients.
   10. Safety Plan.  A personalized and practical plan developed to outline a set of actions to assist a victim with a variety of tools and options, including shelter or alternative housing, adding physical safety devices at the residence (e.g., changing locks), teaching children to call the police or go to the neighbor's home, obtaining protection orders, and deciding the best way to react when danger begins to escalate or erupt.  The plan should be developed with the assistance of a trained advocate, when available, or a trained healthcare provider.
   11. Screening.  Process of determining whether individuals have certain risk factors associated with physical or behavioral health issues requiring assessment.
   12. Sexual Assault.  Refers to a range of behaviors, including but not limited to a completed nonconsensual sex act, an attempted nonconsensual sex act, and/or abusive sexual contact.  Sexual assault includes any sexual act or behavior that occurs when the victim does not or cannot consent.  Lack of consent may be inferred when a perpetrator uses force, threat of force, coercion, or when the victim is asleep, incapacitated, unconscious, or physically or legally incapable of consent.  Victims of sexual assault may or may not know the perpetrator(s) and/or may be involved in a marital, intimate, or dating relationship with the perpetrator.
   13. Strangulation.  Intentionally impeding air passages and/or closure of blood vessels by applying external pressure to the throat or neck of an individual.
   14. Threat.  Any word or action, expressed or implied, made to cause fear for an individual's safety, or for the safety of another person.
   15. Victim.  The person who is the target of the perpetrator, who the perpetrator directs violent or coercive acts toward, which can include physical, sexual, emotional, or psychological harm.
   16. Victim Advocate.  A victim advocate may offer victims and their families a range of services that may include support, crisis intervention, information and referrals, interpretation or translation, and advocacy to ensure the patient's interests are represented, their wishes are respected, and their rights are upheld.

       A number of agencies may offer some or all of the services described above, including community-based victim advocacy programs, law enforcement agencies, criminal justice system victim-witness offices, Tribal social services, adult protective services, and others.  It is important to understand that the information victims share with government-based service providers usually becomes part of the criminal justice record, while community-based advocates typically can provide some level of confidential communication for victims.

       NOTE:  The IHS does not employ victim advocates.

3-31.2  RESPONSIBILITIES

1. Director, IHS.  The Director, IHS is responsible for directing Area Directors to implement and monitor compliance with this policy.
2. Chief Medical Officer.  The IHS Chief Medical Officer (CMO) is responsible for developing, publicizing, and assigning Headquarters staff to assist in the implementation and monitoring of this policy.
3. Area Director.  The Area Director is responsible for ensuring that administrative support and resources are made available in the Area to implement and monitor compliance with this policy.
4. Area Chief Medical Officer.  The Area CMO is responsible for monitoring IHS facilities for IPV policy compliance.
5. Chief Executive Officer.  The Service Unit Chief Executive Officer (CEO) is responsible for:
   1. Ensuring the facility develops local policies and procedures outlining the requirements set forth in this policy for a patient-centered approach to care;
   2. Ensuring the facility's IPV policy is approved and fully implemented, reviewed and updated per Area Governing Board procedures, and submitted to the IHS Area CMO for monitoring purposes;
   3. Ensuring the facility has the necessary equipment for conducting an IPV examination (e.g. digital cameras, tape measures, evidence collection kit supplies, clothing, and traditional healing items);
   4. Ensuring the facility has the capacity for holding forensic evidence in secure and environmentally appropriate conditions;
   5. Identifying a staff member within each facility who will collaborate with the local stakeholders responding to IPV, attend regular meetings, provide community education, and obtain feedback from stakeholders on the facility's IPV response and forensic evidence collection practices and policies;
   6. Ensuring community resources and referrals are identified and available for victims of IPV, including culturally appropriate resources such as traditional healer and language interpreter;
   7. Ensuring all staff receive annual IPV education and that IPVE training is available (refer Section to 3-31.10); and
   8. Addressing the safety and security concerns for patients presenting with IPV and IHS staff members.
6. Facility Medical/Clinical Director.  The facility's Medical/Clinical Director is responsible for:
   1. Developing the facility's IPV policy and procedures in accordance with the requirements set forth in the policy;
   2. Establishing provider supervision for registered nurses practicing as Domestic Violence Examiners;
   3. Ensuring the medical staff receives required annual IPV training;
   4. Encouraging staff to attend didactic and clinical training to perform domestic violence medical forensic examinations; and
   5. Ensuring training records are kept for compliance in each facility and made available upon request by the Area CMO.
7. Facility Chief Nursing Officer.  The facility Chief Nursing Officer is responsible for:
   1. Ensuring nursing staff receive required annual IPV training;
   2. Providing nursing staff the opportunity to attend DVE didactic and clinical skills training; and
   3. Ensuring education and training records are kept for compliance in each facility and made available upon request from the Area CMO.
8. Behavioral Health Director.  The Behavioral Health Director is responsible for:
   1. Ensuring behavioral health responds to the needs of IPV victims, providing counseling and follow-up care, and referring patients for specialty care, as needed; and
   2. Ensuring behavioral health staff receive required annual IPV education, training in danger and lethality assessment and safety planning, and that records are kept for compliance and made available upon request.
9. Intimate Partner Violence Examiner.  The IPVE is responsible for:
   1. Treating all patients with dignity and respect;
   2. Ensuring patient confidentiality;
   3. Providing patient-centered care by responding to the patient in a timely manner, providing privacy and a full explanation of the exam, and allowing the patient to decide which procedures are, or are not, performed during the exam;
   4. Obtaining patient consent to provide a medical forensic exam for the purpose of healthcare with component of evidence collection that may be used as part of a criminal investigation.  (refer to Section 3-31.6 Informed Consent);
   5. Obtaining the medical history, performing the physical exam, treating injuries, providing medications, utilizing approved standing orders, and coordinating additional care that meets the victim's needs (refer to IHM 3-29 Sexual Assault for victims presenting with sexual violence);
   6. Documenting the encounter in the medical record including photographic documentation and paperwork from the evidence collection kit;
   7. Providing prophylactic treatment for STIs and HIV when indicated in accordance with local policies for non-prescribing examiners;
   8. Assessing for pregnancy and providing emergency contraception when indicated;
   9. Providing pain management per facility policy;
   10. Coordinating with an advocate, if available, for crisis intervention, support, and advocacy before, during, and after the exam;
   11. Coordinating with local law enforcement when requested by the patient;
   12. Conducting a danger and lethality assessment and developing a safety plan;
   13. Arranging follow-up appointments for medical, oral, forensic, and behavioral health;
   14. Providing a list of local resources such as the victim advocate, shelters, and emergency phone numbers with the understanding the patient may not want to have written information for privacy and safety reasons;
   15. Maintaining integrity of evidence and chain of custody according to policy and legal requirements;
   16. Transferring evidence and/or photographic documentation to law enforcement in accordance with the signed patient consent specific to the event; and
   17. Notifying his/her Supervisor and/or the facility CEO on receipt of a subpoena to testify in court.

3-31.3  SCREENING

Universal and routine screening for IPV shall be conducted in private by healthcare providers on all female patients aged 14-46 years as recommended by the USPSTF. Discuss treatment and referral options for all positive screens for assessment, and intervention (refer to 3-31.8H).

NOTE: Mandated reporting requirements must be discussed before screening.

3-31.4  REPORTING

1. During screening and in obtaining consent, inform the patient of any limits to provider/patient confidentiality.
2. Federal Mandate. There is no Federal mandate to report IPV, and federal laws may restrict reporting without the patient's consent (refer to Section 3-31.5, Confidentiality). Nonetheless, providers should be aware of Tribal and State laws and regulations. When faced with concerns about safety following the Danger and Lethality Risk Assessment (refer to Section 3-31.8G), the facility's policy shall outline situations of mandated reporting developed in coordination with the Office of the General Counsel (OGC) regional attorney.
3. Disclosure of health information of IPV victims must respect patient confidentiality and autonomy, and serve to improve their safety and health status. Consult the facility Health Information Manager and/or OGC regional attorney regarding applicable reporting laws and release of health information (refer to Sections 3-31.4 and 3-31.6D).

3-31.5  CONFIDENTIALITY

Confidentiality.  Medical records of IHS program patients, including records contained in the IHS Privacy Act System of Records Notice 09-17-0001 Medical, Health, and Billing Records, are subject to the following laws:  Privacy Act, 5 U.S.C. § 552a; Freedom of Information Act, 5 U.S.C. § 552; Drug Abuse Prevention, Treatment, and Rehabilitation Act, 21 U.S.C. § 1101; Comprehensive Alcohol Abuse and Alcoholism Prevention; Treatment and Rehabilitation Act, 42 U.S.C. § 4541; Health Insurance Portability and Accountability Act (HIPAA); Confidentiality of Medical Quality Assurance Records, 25 U.S.C. § 1675; Patient Safety and Quality Improvement Act of 2005; 42 U.S.C. §§ 299b-21 to -26; and Federal regulations promulgated to implement those acts, including the HIPAA Privacy Rule (45 CFR Parts 160 and 164).

Note:  Unless Federal laws or regulations provide otherwise, State laws requiring disclosure of protected health information (PHI) do not apply to the IHS.  When medical records and other PHI are needed for use or disclosure not authorized by Federal law, the written authorization of the patient and/or a valid court order or subpoena is required.  Consultation with the regional OGC is encouraged to ensure that all uses and disclosures of medical information under this policy are compliant with the law.

3-31.6  INFORMED CONSENT

1. Informed Consent.  An informed consent procedure shall be developed for each facility.  In order for the patient's consent to be valid, the patient must have the decision making capacity to voluntarily consent to the medical forensic examination.
   1. There are two consent processes:
      1. Medical evaluation and treatment
      2. Evidence collection, including photographic images, colposcopic images, medical forensic examination, and toxicology screening, if indicated.
   2. Consent elements of the IPV Exam includes, but is not limited to:
      1. An explanation of the medical forensic examination, with:
         1. evidence collection and reporting to law enforcement; or
         2. anonymous evidence collection (refer to Section 3-31.9).
      2. The ability to receive medical care without the collection of evidence or reporting to law enforcement;
      3. Explanation of evidence, including photographic evidence;
      4. The ability to accept or decline any aspect of the examination;
      5. Explanation of laboratory specimens, imaging studies, medications; and
      6. Access to advocacy services.
2. Minors.  Age of informed consent for the medical examination is governed by the law of the State where the IHS facility is located (refer to IHM, Part 3-13 Section 8).  When developing local policy and procedures, any questions regarding this provision must be directed to the OGC regional attorney.
3. Patients Under the Influence of Drugs or Alcohol.  The patient's decision-making capacity to provide informed consent should be based on clinical judgment and in accordance with IHS policy.  In the development of local policies and procedures, consult the OGC regional attorney, as well as Service Unit and Area risk managers regarding applicable consent laws.  (For more information, refer to Sections 3-3.13 to 3-3.14 IHM and Chapter 6, IHS Risk Management Manual.)
4. Patient Authorization.  Written patient authorization may be required to release photographic images, medical records, and evidence to law enforcement; also for the purpose of contacting the patient after a medical forensic examination for case management, follow-up testing, and for making referrals.  Prior to disclosing health information (including the release of domestic violence medical records and photographic images), Form IHS 810 - "Authorization for Use or Disclosure of Health Information" must be completed and signed.  Consultation with the OGC regional attorney is encouraged to ensure that all uses and disclosures of medical information under this policy are compliant with the law.

3-31.7  CHAIN OF CUSTODY

1. Training.  All staff involved in obtaining, handling, and transferring evidence, including photographic documentation, must be properly trained in properly evidence preservation techniques and in maintaining the chain of custody in accordance with local law and crime lab procedures.
2. Maintenance.  Maintain the evidence in a manner that ensures the evidence has not been tampered with or contaminated between collection and transfer to the appropriate law enforcement agency.
3. Documentation.  From the moment the evidence is collected, every transfer from person to person must be documented.  The transfer of evidence to law enforcement should be noted in the health record, including name, agency, time, and date.
4. Transfer of Evidence.  Facilities may temporarily hold evidence in a secure location under environmentally appropriate conditions until it is transferred to law enforcement.

   NOTE:  Storage of evidence is the role of law enforcement agencies.

3-31.8  UNIFORM CLINICAL CARE GUIDELINES

1. Intake Procedures.
   1. Reception/Intake/Registration.  All patients presenting with a report of IPV shall receive priority treatment.  Maintaining confidentiality at this initial point of contact is critical to privacy, safety, and the provision of trauma-informed care.
   2. Triage.  All patients with IPV shall be triaged as priority treatment patients.
   3. Priority Treatment.  Priority treatment is implemented by immediately moving the patient to a private exam room or private waiting area, away from the main waiting areas and other patients.  The patient's privacy and safety must be ensured, their presence in the facility is not to be disclosed, and visitors are only permitted with patient consent.
2. Patient Safety.  Patient safety must be ensured by notifying security, non-disclosure of the patient's presence in the facility, allowing visitors only with patient consent, and requesting law enforcement presence, if needed.
3. Trauma-Informed Care.  Trauma-informed care addresses the patient's physical, psychological, and emotional safety with an approach that involves understanding, recognizing, and responding to the effects of trauma.
4. Physical Environment.  Facilities shall provide a safe environment for confidential medical history taking, examination, treatment, and intervention services.
   1. Written materials related to IPV are made accessible in areas such as examination rooms, restrooms, and public waiting areas.  The supply of brochures should be routinely re-stocked and should contain current information about community resources to assist victims of IPV.
   2. Posters designed to educate patients, perpetrators, concerned family members, and others about the nature and dynamics of IPV should be prominently displayed in examination rooms, restrooms, and waiting areas, and should be culturally and linguistically relevant to the members of the community.
5. Intimate Partner Violence Medical Forensic Examination.  Involves a thorough physical examination, treatment of injuries, medications, follow-up, referrals, safety planning, and documentation.
   1. (1) Medical forensic examinations include all aspects of the physical exam and, where specific informed consent is granted, collection and preservation of evidence, written and photographic documentation, and follow-up care.
   2. Wherever available, the examinations should be performed by an examiner with specialized education and clinical experience in the collection of forensic evidence and treatment of these patients.  However, the examination can also be performed (and should be when it is necessary) by a practitioner who does not have the additional specialized training and experience.
   3. Sexual assault often co-occurs with IPV, and is included in the assessment, and guides the medical forensic exam.  (For additional guidance, refer to IHM Chapter 29 Sexual Assault.)
6. Strangulation.  Poses significant morbidity and mortality risk.  All facilities shall develop detailed policies and procedures in the clinical care of patients with strangulation histories.
7. Danger and Lethality Risk Assessment.  A danger and lethality risk assessment shall be conducted following the disclosure of to establish a standard and consistent framework for the evaluation of assault risk.  When faced with concerns about patient safety and mandated reporting requirements, contact your OGC regional attorney (refer to Section 3-31.4).
8. Intervention and Discharge Planning.  Victims of IPV will receive intervention and discharge planning services:
   1. Offer verbal recognition, validation, and concern to patients, while also advising the patient on the limitations of confidentiality;
   2. Construct an in-depth discharge safety plan with the patient in coordination with behavioral health and victim advocate services (if applicable);
   3. Arrange follow-up and referrals for medical, oral, forensic, and/or behavioral health care appointments; and
   4. Provide written resources on IPV including traditional healers, faith-based organizations, and support programs.
9. Documentation.  All information from the encounter shall be documented in the patient's medical record, under restricted access, including: the chief complaint; relevant history; results of the medical examination; results of laboratory and other diagnostic procedures; body maps; photographs; results of the health, safety, danger and lethality risk assessment; interventions; discharge planning; and referrals.

3-31.9  ANONYMOUS EVIDENCE COLLECTION KITS AND NON-REPORTING

1. Anonymous Evidence Collection Kits.  If the patient is reluctant to report the assault to law enforcement, the health care provider will inform the patient of the option of conducting an intimate partner violence medical forensic examination, collecting the forensic evidence, and storing the evidence as an anonymous sexual assault evidence kit.  Local policies and protocols must address how the kit will be destroyed, removal of any identifiable patient information prior to disposition, and obtaining patient authorization to contact her/him after the assault.
   1. Anonymous evidence collection kits shall be labeled with a unique alphanumeric identifier.  Medical record and patient account numbers may not be used as a unique alphanumeric identifier.
   2. The storage and destruction of evidence collection kits is the responsibility of law enforcement.
2. Non-Reporting.  Victims of IPV shall not be required to report the IPV to law enforcement in order to have access to a medical examination or to have evidence collected.

   NOTE:  There may be a rare instance in which a subpoena is issued requiring testimony which reveals the identity of an anonymous evidence collection kit. If faced with this situation, contact your OGC regional attorney (refer to Section 3-31.11).

3-31.10  TRAINING AND CONTINUING EDUCATION

1. All Staff.  All staff are required to receive annual IPV education.
2. Licensed Health Care Providers.  All licensed members of the health care team (physician, advanced practice nurse, physician assistant, registered nurse, behavioral health, dentist, and hygienist) accessing and documenting in the medical record will be provided IPV education during orientation, to be repeated annually:
   1. One hour of mandatory education on IPV screening and dynamics, and
   2. One hour of education ono appropriate clinical responses to patients who report IPV.
3. IPVE.  Training is required for those conducting medical forensic examinations for IPV.
   1. Prerequisite:  Sexual Assault Examiner 40-hour training course.  (SANE certification is not a requirement at IHS facilities);
   2. Intimate Partner Violence Examiner 24-hour training course; and
   3. Two-hour minimum annual training requirement on relevant intimate partner violence training obtained through webinars and clinical skills training, or conference attendance.
4. Credentialing and Privileging.  The training specified in this policy shall be part of the Area and local facility credentialing and privileging policies for physicians, physician assistants, and advanced practice nurses conducting medical forensic examinations.
5. Competencies.  The training specified in this policy shall be part of the competencies for registered nurses to conduct medical forensic examinations, and shall be addressed in Area and local facility policies.  Competency is determined by the professional assessing the required clinical skills.
6. Continuous Quality Improvement.  All facilities providing onsite medical forensic examinations must have a processes in place for continuous quality improvement and review of all examinations conducted.

3-31.11  RESPONDING TO A SUBPOENA

As detailed in the Indian Health Manual Part 5, Chapter 27 - Responding to Requests for IHS Employee's Testimony or IHS Documents in Proceedings where the United States is not a Party.