Comprehensive Sexual Assault Examination Response

State: FL Type: Model Practice Year: 2012

Brevard County has a population of over 550,000 persons, and has approximately 150 reported cases of sexual assault. Prior to this practice, 100% of these cases were seen in the local Emergency Departments (EDs). Since the implementation of this practice in May of 2006 the number of victims seen at EDs has been reduced by 70% with some EDs reporting a 90% reduction due to their proximity to the center. The goal summary is to: Provide compassionate, comprehensive, individualized care to victims of sexual assault in a comforting environment. The objectives were: to provide 24/7 comprehensive, individualized care, in an outpatient secure environment, to reduce law enforcement time, and to reduce the number of victims being seen in an ED setting and thereby reduce cost while providing better service to the community. The practice was implemented through a partnership between the Office of the State Attorney (SAO) 18th Judicial Circuit, Sexual Assault Victim Services (SAVS), Salvation Army’s Domestic Violence Shelter, and the Brevard County Health Department (BCHD). The SAVS Foundation obtained a $20,000 grant to support on-call payment. The SAO pays the medical providers for the forensic exam through a victim’s advocacy fund. The Health Department contributed $6,000 of in-kind administrative cost, non-reimbursed medical support, and medical supply cost including prophylaxis medication. The Salvation Army contributed a renovated facility that houses the exam room in a very secure location and obtained local donations for other medical supplies and office supplies. In the three and one-half years of operations, this program has managed the care for over 296 victims of sexual assault. Over 70% of the total volume of sexual assault in the county is now seen outside of emergency departments (ED). The net effect is a reduction in time for the victim and law enforcement, an increase in emergent care capacity, a decrease in overall cost, and an increase in continuity of care for the victim with linkages to ongoing community services. All of the objectives were met due to relying on the strength that each partner brought to bear in addressing this issue. The LHD had the nursing staff, the State Attorney had the start up money and technical expertise, and the Salvation Army had the facility and the experience with battered women.
Health Issues Sexual Violence (SV) is a significant problem in the United States. In the United States, 1 in 6 women and 1 in 33 men reported experiencing an attempted or completed rape at some time in their lives. Sexual Violence can lead to long term health problems to include; chronic pain, STD, unwanted pregnancy, headaches, and stomach pain. Sexual Violence can have significant emotional impact as well, usually manifested as fear and anxiety. Feelings of anger and stress can create and lead to issues of trust, wariness of involvement with others, eating disorders, intrusive memories of the assault and major depression to the point of suicidal ideation. Victims of SV need to be appropriately managed by both the legal and the medical community since this is an issue of criminal activity as well as health. With the events of Sept 11, local systems became more fluent and aware of various resources and processes within the community. This is especially true with regard to the emergency medical system, law enforcement and the local county health department due to disaster preparedness planning and exercising. There was currently a system in place to deal with the public health issue of sexual assault but as agencies began to become more familiar with one another, current practice was reviewed and questions were raised as to resource allocation and process improvement. The Sexual Assault Victims Services (SAVS) took the initiative to address the long waits in emergency departments as well as the added expense to ED’s and law enforcement not to mention the victim’s experience. The SAVS office then contacted the Brevard County Health Department to see if there would be a better way to address this public health issue as well as the Salvation Army to get input from the victim services side. The overarching relevancy to the community is capacity, time management, and cost effectiveness. This innovative collaborative effort addresses the issue of SV by improving upon the delivery of services to victims and maximizing existing community resources. Through a coordinated effort, examination of victims is now accomplished at the most appropriate venue with the least amount of time and expenditure. Emergency departments now have additional capacity to practice emergency medicine, law enforcement has more time to devote to investigative work, and victims receive care within the network that will follow them post traumatic event. The victim is seen in a shorter time period for forensic exam, there is reduced time for the investigative interview, follow-up exams are scheduled on the spot at the local health department (LHD), and victim support services are readily available, which includes protective sheltering. Innovation We began with an endpoint in mind. The following questions were at the forefront of our strategic meetings and helped to clarify the vision. Would a change in practice benefit anyone and if so, who? Was this a valuable service that would be of tangible benefit to both the community as well as to the agencies involved? Was it possible to achieve the desired results given the challenges and constraints? Once these questions were answered as YES, it became easy to implement the MAPP process. The practice is not completely new to the field of public health. Through networking and internet searches there are several private foundations that practice using a similar model (Fort Wayne). In addition, there are LHD’s who have partnered to contract these services within the community or have provided varying degree of support in order for exams to occur outside of the emergency room. In essence, a modified MAPP process was used to develop this practice within our community. Partnership development is an ongoing process and essential in today’s fiscal crisis. From the outset, the vision for this center and practice was the driving force behind bringing everyone together to make it happen; improve care to victims and maximize community resources. Assessments were made within each stakeholder agency to ensure that their strengths were brought to the practice along with their ability to leverage change within the community. Strategic planning was accomplished along with formulating goals and strategies to achieve a unified vision. Planning, implementation and evaluation completed the process. In following the MAPP outline, this practice was able to be up and running ahead of schedule and required very few adjustments during startup. Of the approaches that exist, this is the only one where the LHD has the lead medical role and has partnered with the major investors to accomplish a fundamental change in the delivery of services. There are programs where an individual LHD employee is contracted to provide forensic exams either in a private office and or  emergency room setting. In addition, there are programs where the LHD provides some administrative contract management as well as some personnel for exams. This program is unique in that it forms a strong bond between those most affected: the victim, the emergency department, local law enforcement, local social services, the LHD, and the State Attorneys office (including the Sexual Assault Victims Services division). In addition, there has evolved support at decision making levels within the community. The police chiefs, hospital Vice Presidents, Health Department Director, States Attorney, and Directors of sheltering and advocacy are all engaged in this process.  
Primary Stakeholders State Attorneys office Sheriffs office nine city police offices Salvation Army Six hospital Emergency Departments Sexual Assault Victims Services Victims of Sexual Assault Brevard County Health Department Role of Stakeholders/Partners The community as a whole was extremely involved in this process. The SAVS reached out to both the emergency departments of six area hospitals, the county sheriff department, ten municipal police departments, the LHD, as well as engaging their existing partnerships such as the Salvation Army’s Domestic Violence Shelter. Each stakeholder had a vested interest in making every effort to ensure the practice succeeded. The SAVS office, LHD and State Attorney's Office had the lead in planning and implementing this practice. Other stakeholders were kept appraised of progress and demonstrated their overwhelming support as each law enforcement agency, most emergency departments, and countless community service organizations were represented at the facility open house. In addition, various agencies had gathered donations such as clothing for the victims, digital camera, computers, exam tables, and a plethora of start up equipment needed to open the doors. LHD Role The Local Health Department’s (LHD’s) role in this practice is to provide the medical personnel, prophylaxis, some durable supplies, and medical administrative oversight to the exam center. All forensic examiners are either full or part-time employees of the LHD. All timesheets for on-call and examinations are prepared and paid through the LHD, although the funding comes from the Sexual Assault Victims Services (SAVS) funds. The SAVS office is billed on a monthly basis for on-call salary. The Bureau of Victim Compensation is billed on a case by case basis using their Sexual Battery Claim Form (same form used by emergency departments). Exam and prophylaxis protocols are developed and maintained by the LHD. In addition all medical supplies including medication for sexually transmitted disease and emergency contraception are provided by the LHD. All cases are coordinated and filed through the LHD Community Health Director’s office. Although this was a new hands on practice for the LHD, the desire to be active in direct services has been a mainstay of this LHD given the obvious rewards of actively taking care of the community The Brevard County Health Department (BCHD) maintains a very visible presence within the community via provision of direct services as well as providing technical assistance and expertise to numerous boards and community action groups. An example would be the relationship between the BCHD and the local hospitals to provide surge capacity during disasters as well as implementing a maternity program whereby all women in the county have access to prenatal care. Specifically with this practice, the BCHD is a conduit for all aspects of medical care and communicates weekly with the SAVS office. In addition, all stakeholders participate in a quarterly working lunch at a local restaurant to discuss sex crimes within the community. This collaborative face to face effort fosters communication and system improvement. The BCHD collects and analyses data from each sexual assault and shares findings with stakeholders at those meetings. Lessons Learned Of the lessons learned, nothing takes the place of meeting people face to face. In addition, knowing how a service or product will benefit each partner is essential. For law enforcement is was time reduction, for hospitals it was eliminating services that could be better performed elsewhere with a better trained staff to do it, for the Advocacy group it was personalized care, and for the LHD it was being a team player with int community when possible. Of the barriers, there were no surprises. Dealing with busy schedules, resource allocation and sustainability in a volatile market. Implementation Strategy The Brevard County Health Department was contacted by the Sexual Assault Victims Services in summer of 2005 and a strategic planning meeting was arranged for Sep 2005. Each agency had their unique interagency challenges, but the goals and objectives were the focal point of the design and implementation of the center. Sep 05 – Strategic planning meeting. Is the project doable? What did we want to accomplish? What would the benefit be to the client, to the health system, to law enforcement? Is this part of the Public Health mission? In addition, questions regarding personnel, funding, impact, specific goals, and partnerships were discussed. Conclusion – proceed with the project. Oct 05 – Operations meeting. Specific elements were addressed such as volume of exams, how to accomplish 24/7 coverage, training of examiners, reimbursement issues, personnel issues, equipment etc…Each agency to determine feasibility. Nov 05 – Feasibility meeting. All agencies agree project is feasible and of great benefit to the community. Feasibility will hinge on ability to obtain funding with the biggest concern being the on-call provider funding. Brevard County Health Department (BCHD) Sr. management team was presented the project and the project was embraced with approval to pursue and implement. Dec 05 – BCHD staff were approached regarding interest. Operations meetings were held regarding supplies, protocols, documentation, invoices, training and all other details were identified and addressed. Jan 06 – Funding has been assured. On-call pay and building renovations are resolved. Details continue to be sorted out and initial provider training will be available in March. Feb 06 – Final training preparations made, draft contract initiated, fine tuning. Mar 06 – Four BCHD practitioners trained, status of new facility addressed and center projected to open 01 May 06. Apr 06 – Final preparation. Contract amended, BCHD staff trained on all procedures, on-call schedule is created, personnel issues resolved, equipment is in place, and staff is eager for the center to open. Open house held at center with all partners and directed at law enforcement agencies to familiarize them with process and to answer questions. 01 May 06 – Center is opened The confidence level for receiving funding for this project was fairly high at the outset and allowed for the expeditious implementation of the center. At the strategic planning meeting it was hopeful that the center would open in one year (by the fall of 2006) given the facility renovations, training, and varying specific nuances and challenges encountered by each agency. The planning took approximately six months with an additional three months for implementation once funding was secured. Personnel issues including recruitment, training, policies and protocols took four months.  
Process & Outcome 1. Provide 24/7 comprehensive, individualized, victim centered care in an outpatient secure environment 2. Reduce the amount of time law enforcement spends on initial investigation of rape as well as the time the victim is at the facility Objective 1: Performance measures included: 1. Provide 24/7 coverage for 365 days of the year 2. Accurate evidence collection and prophylaxis of each victim for STD and pregnancy prevention 3. Evaluation of overall experience of the victim 4. Community involvement. Data Collection: 1. Provider coverage for the center is posted via a calendar indication who takes call for each shift. The data is collected by the SAVs office and posted each month indicating coverage. 2. Of the 411 cases of sexual assault, only two cases had opportunities for improvement. These data were collected via chart review by the LHD and indicate that all victims were appropriately prophylaxed, and two cases the collection of specimens could be improved. 3. 52 victims and advocates were queried regarding the examination experience and all 52 identified both professionalism and compassion in their care. These data were collected by the victim’s advocates via survey. 4. All ten local law enforcement agencies are engaged along with all six hospitals. We have held over 20 community meetings and have established a county wide policy for where and who will conduct these exams. These data are collected by one of the law enforcement agencies and one of the hospitals. Evaluation results: The LHD learned the commitment the community has with regard to this service and the complexity of coordinating with multiple agencies and there specific needs. This objective was not overwhelmingly achieved, but has garnered additional support in the area of additional funding. Feedback: Data are shared with all partners and results are broad in reach. Law enforcement and State Attorney Office’s provide positive feedback with the evidence and documentation accuracy which affects trial outcomes. Staff and victims report care outside of the ED is much more conducive to how the victim feels and the overall experience. A modification made was the forensic lab recommended to not over collect evidence. Some examiners in an effort to be accurate were over collecting samples which burdened the lab. Through inservice and discussion, examiners are much more systematic in collecting the evidence that is likely to be worthwhile. This feedback loop is ongoing. Objective 2: Performance measures included: 1. Reduction in time for both law enforcement and victims with regard to evidence collection 2. Numbers of rape cases and the timing of when the crime occurs by precinct Data Collection: 1. The time law enforcement spends at the rape center is collected by the LHD with the average being two hours. These data correspond with the victim time as well. 2. The 411 rape cases are broken down by when the examiner is called out, the time the rape occurred and location of the rape. LHD collects the times and law enforcement the locations. These data are then plotted on a graph by event time and agency response. Evaluation results: 1. The time the victim and law enforcement are at the rape center averages two hours. This is a reduction by 50% from the previous process of performing exams in the emergency department which typically took four hours to perform. 2. The data collected from each case shows that most rapes occur at night and more specifically from midnight to six a.m. (65%) and on Sunday (23%) and Thursday (29%). The Sheriffs office investigates the most cases of rape (30%) compared to the nine local precincts. Feedback: Data are shared with all partners. Through quarterly luncheons, law enforcement, examiners, attorneys, victim advocates, hotline operators all discuss processes and ways to improve. Initially there were disconnects with getting law enforcement and the examiner at the facility at the same time. Through this networking and open discussion, a process was implemented that had the examiner and officer arriving at the site 95% of the time within 15 minutes of each other. Additionally, the Sheriffs office is identified as more experienced with cases and offers training to local precincts with regard to case investigation. The data around the day and time of the rape came into play when opening a new site. We used these data to direct the days/hours the new site would be open in order to provide the largest benefit with the least amount of resources. The objective has been met above what was anticipated.
There is no question regarding the intent to continue this practice and 100% of stakeholders are committed to the practice. There is overwhelming evidence to support the cost savings, time savings, agency efficiency, community benefit and positive feelings of job satisfaction resulting from the care of victims and partaking in the process to get criminals off the street. Each agency involved has the commitment of the highest leadership as well as operational support. Feedback from the hospitals, law enforcement, social service agencies and the victim themselves has all been full of accolades and recognition of community and individual value. Funding remains the primary burden for sustainment. The biggest challenge will be to replace the grant for the on-call funding, which goes through 2010. The LHD is strongly committed to this project as it has remained virtually budget neutral. As the fiscal crisis continues, there may actually be too many staff who volunteers for the practice, but staffing has remained stable for two years. Communication between all stakeholders has been paramount in projecting the value of this service. The plans to sustain this practice stems primarily from the ability to maintain as well as acquire adequate funding. The majority of current resources are generated out of the Florida legislature who funds the Sexual Assault Victims Services (SAVS) program and provides $500 for each forensic exam, regardless of what entity provides the exam. This funding adequately covers the LHD salaries, supplies, pharmaceuticals, and most of the administrative costs keeping the LHD virtually budget neutral. The LHD has been extremely creative with regard to fulfilling its role and responsibility regarding this practice. The grant allocated to cover the on-call payment is in place until 2010 but it is unknown whether this opportunity will remain long term. Efforts are being made by the SAVS office to leverage another funding source to cover these expenses rather than rely on grants.
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