Aware of the high prevalence of traumatic experiences including interpersonal violence (IPV) in the safety-net setting and the devastating impact of IPV on mental and physical health, a team at the University of California, San Francisco (UCSF), implemented a multi-sector partnership program called ARISE (Aspire to Realize Improved Safety and Equity) to improve the health and safety of adults and children affected by IPV. Through ARISE, we launched an IPV program by successfully aligning our program goals with the primary care–behavioral health integration goals of the San Francisco Health Network (SFHN), the public health care delivery system in San Francisco. Our collaboration resulted in a key innovation, called the “Behavioral Health Vital Signs,” which catalyzed trauma-informed quality improvement efforts in primary care to address IPV in conjunction with depression and alcohol and substance use.
It is feasible to screen all primary care patients concurrently for depression, alcohol and substance use, and IPV across the lifespan, though disclosure rates of IPV on a screener are likely be lower than true IPV prevalence.
The development of a Behavioral Health Vital Signs (BVHS) screening tool and quality improvement initiative that included depression, alcohol and substance use, and IPV across the lifespan enabled a safety-net health care system to prioritize addressing IPV, despite the lack of a payment incentive specific to IPV.
The BHVS was a key component of an overall systems approach toward institutionalizing a trauma-informed IPV program that included provider and staff training, screening and response protocols, electronic health record (EHR) templates and data, continuous quality improvement, patient education, and expedited referrals.
Designating BVHS to be a highly prioritized primary care metric (a “True North” metric) can be used to drive behavioral health leadership in trauma-informed care.
The BVHS initiative is a promising mechanism to align health care system incentives to support a more trauma-informed approach to primary care–behavioral health integration.
Interpersonal violence (IPV), which includes but is not limited to violence occurring between individuals in intimate relationships, can occur across the lifespan, is highly prevalent, and often leads to devastating impacts on health. Often, mental health and substance use disorders are consequences of experiencing violence across the lifespan and, therefore, co-occur and are inter-related with IPV in myriad and complex ways. IPV is inadequately addressed in most health care settings, often a result of a failure to implement a systems approach.
In parallel, large percentages of people suffering from mental health and substance use disorders in the United States are under-diagnosed and inadequately treated. Furthermore, the complex inter-relationship between IPV and co-occurring mental health or substance use disorders is often not identified. Each of these inter-related conditions can have direct adverse health effects, undermine patients’ abilities to manage other chronic health conditions, increase overall health care utilization and costs, and lead to increased morbidity and mortality.
Simultaneously, public sector health care financing is shifting from fee-for-service payment to value-based capitated contracts and pay-for-performance models. There is an increasing recognition that screening for and addressing mental and behavioral health are key strategies to improve care and reduce health care costs. There now exist national quality benchmarks, performance measures, and quality improvement incentives related to screening for depression and substance use, but not for exposure to IPV across the lifespan.
In the San Francisco Health Network (SFHN), the safety net health care delivery system of the San Francisco Department of Public Health (SFDPH), about 75% of the patient population is insured by Medicaid (MediCal) plans. The network participates in the California’s Public Hospital Redesign and Incentives in MediCal Program (PRIME), which includes incentivized performance metrics for depression and alcohol and substance abuse disorders, but not IPV. Despite a long history of pioneering and innovative leadership in both IPV prevention and primary care–behavioral health integration in select clinics, the SFHN had not previously institutionalized a trauma-informed program to address IPV and co-occurring mental health and substance use disorders.
Recognizing that depression, alcohol and substance use, and interpersonal violence (IPV) across the lifespan are powerful and frequently interconnected mediators of patients’ health outcomes, SFHN Primary Care leadership established an internal Behavioral Health Vital Signs performance metric, and implemented an associated screening tool and quality improvement process to address these conditions more effectively. In collaboration, SFHN and ARISE developed the BHVS screener, a six-question patient questionnaire for depressive symptoms, alcohol and substance use, and IPV, thereby streamlining primary care behavioral health initiatives into a single workflow using an integrated approach. By elevating the BHVS to be a “True North” (highest priority) metric, we aimed to achieve multiple shared strategic goals. Once we established the BHVS as True North for 2018–2019, our goal was to administer the BHVS to at least 36% of our active primary care patients over 12 years old by June 30, 2019, a 20% relative improvement over the previous year’s baseline, while simultaneously increasing depression screening rates from 44% to at least 53%, a relative improvement of 23%.
The Setting and Foundational Work
In 2014, the SFHN was formed to unify the public consortium of primary care, youth-focused, and women’s clinics that serve approximately 55,000 highly diverse, low-income patients in both hospital-based academic and community-based practices with the safety-net hospital, a long-term care facility, and jail health. An affiliation agreement between SFDPH and UCSF governs shared responsibility for care delivery. The SFHN employed funds available through a federal waiver program for systems redesign (DSRIP funds) to place behavioral health clinicians in all primary care clinics. System-wide quality improvement priorities, aligned with state and national performance metrics and associated incentives, became a guiding force for the improvement work across the network. Data visualization dashboards for tracking progress and a monthly meeting structure for clinics to share best practices were instituted.
Shortly thereafter, the SFHN agreed to partner with and serve as the implementation site for a competitive IPV proposal (ARISE) to the federal Office on Women’s Health, led by a team of UCSF faculty clinician-researchers who practice primary care in the SFHN clinics and have expertise in IPV and trauma-informed care, primary care, and implementation science. In 2015, ARISE was awarded the grant and began to strategize with SFHN leadership and build health care-community partnerships to support its implementation in the SFHN’s primary care, youth-focused, and women’s clinics. ARISE formed collaborative partnerships with a community-based domestic violence advocacy organization, La Casa de las Madres; a legal aid organization, BayLegal; a trauma-specific treatment organization, The Trauma Recovery Center; and a national non-profit violence prevention resource center, Futures without Violence.
Almost immediately, the UCSF team and the SFHN encountered challenges to implementing ARISE. Because of concerns about overburdening the dedicated safety-net staff with competing demands, and the possibility of losing more than $3 million of state Medicaid waiver incentives each year for not meeting depression, alcohol, and substance use disorder benchmarks, ARISE’s planned IPV screening and response initiatives were halted. ARISE shifted its focus to formalizing its capacity-building partnerships and providing technical assistance to clinics about IPV and trauma-informed care.
A New Trauma-Informed Approach
This implementation hurdle was surmounted through the development of a novel, combined behavioral health screener and associated workflow process. The SFHN and ARISE leadership teams came together and determined that leveraging two existing quality improvement (QI) metrics with incentive dollars tied to them (depression and alcohol/substance use) with the unfunded but critical need to screen for experiences of IPV across the lifespan might synergistically improve our health care delivery system by (1) educating staff about the health impacts of IPV and co-occurring mental health and substance use disorders, (2) promoting more effective, trauma-informed team-based care, (3) augmenting the leadership capacity of the primary care behavioral health (PCBH) teams, and (4) reducing the burden on patients and staff with a single screening tool and workflow. This collaboratively developed screening tool and QI initiative was the BHVS.
The BHVS tool (Figure 1) contains four previously validated questions to screen for symptoms of depression, alcohol, and substance use and two IPV questions. The IPV questions were recommended by ARISE based on validated intimate partner violence screening tools and our prior experience, and were designed to be accessible to lower literacy populations, avoid stigmatizing words, and be easily translatable into multiple languages. The BHVS IPV questions allow patients to disclose being harmed by anyone at any point across the lifespan, reflecting the epidemiology of IPV, especially in safety-net populations, and the evidence about its impacts across the lifespan. Additionally, ARISE provided an educational message to precede the questions and a checklist of coping behaviors and resilience factors to facilitate patient-centered conversations about preferred healing practices.
The SFHN Primary Care Behavioral Health Quality Improvement (PCBH QI) Team was formed and tasked with leading the BHVS workflow development and implementation. The ARISE team provided technical advice about IPV and trauma-informed care. Using LEAN strategies in four pilot sites, key drivers were identified and countermeasures were tested and refined to develop a standardized, team-based workflow in fiscal year 2017–2018.
To promote implementation across clinics, the SFHN Primary Care leadership team chose BHVS screening as a True North metric for the 2018–2019 fiscal year. The True North designation mandated that all of the primary care clinics prioritize this performance metric and provided each clinic with technical assistance and support by the PCBH QI team, as well as informatics resources to compile and present weekly performance data with clinic-level visualization tools.
ARISE IPV Advocacy: Preparing a System to Address IPV
ARISE formalized a partnership that co-located an ARISE IPV Advocate from La Casa de las Madres, a community-based domestic violence organization, into the SFHN. This advocate is available to respond immediately to patients from the five hospital-based clinics who disclose IPV or “relationship stress or issues” to the health care staff. ARISE trained more than 1,700 health care staff and providers on (a) trauma-informed care principles and (b) a Universal Education (UE) method of addressing IPV whereby providers, irrespective of IPV disclosure, share information on how relationships affect health, how IPV could be related to patients’ health concerns, and how patients can access helpful clinic and community resources. Finally, for patients who disclose current or recent IPV, ARISE offers phone outreach to reinforce available IPV clinic and community resources and invite patients to evaluate their experience with ARISE.
BHVS Standard Work and Response
The SFHN PCBH QI team developed a standard workflow to ensure that the BHVS is administered to patients annually during the rooming process for a primary care visit. Most clinics administer paper versions of the BHVS, with verbal assistance by medical evaluation assistants (MEAs) for those patients who leave the form blank. Patients can decline to answer any or all questions. MEAs record all responses into a standard template in the EHR. Positive patient disclosures on the BHVS result in immediate follow-up (Figure 2).
PCBH clinicians offer a series of six treatment sessions (with an option to extend if needed), utilizing motivational interviewing techniques and cognitive behavioral therapeutic interventions, to patients likely to benefit from a short-term treatment model. The PCBH teams also facilitate referrals to community-based specialty mental health and to community-based substance use disorders support services and treatment for patients who require more intensive treatment models. The PCBH teams follow such patients closely to help them overcome obstacles and stigma in engaging in more intensive care. When patients do not engage with the PCBH clinicians, primary care providers can consult with onsite PCBH clinicians (and the ARISE IPV Advocate and consulting psychiatrists) for assessment and management advice.
The BHVS initiative is led by the PCBH Quality Improvement Team, which consists of the Director of Primary Care Behavioral Health, the Primary Care Director of Population Health and Quality, the QI Coordinator for Public Hospital Redesign and Incentives in Medi-Cal (PRIME), PCBH supervisors, the SFHN Primary Care psychiatry supervisor, and the ARISE team (Figure 3).
Metrics and Results
The implementation of the BHVS led to improvement in screening rates for all three conditions (Figure 4). The SFHN is currently on target to meet its metrics for the Public Hospital Redesign and Incentives in MediCal (PRIME) program in depression screening and follow-up and substance use screening and response. The increase in depression screening rate as shown in Figure 4 shows a shift with more than 6 points above the median suggesting this change in screening rate is not explained by random variation alone. In addition, to date, 44% of patients have been screened for lifetime IPV.
The BHVS initiative has resulted in screening more individuals who may not have been at highest risk for these conditions and, thus, in a slight decrease in the rate of positive screening results (Figure 5). However, due to the much larger number of individuals screened, the overall number of patients with positive disclosures increased for all conditions between July 1, 2018, and June 30, 2019 (Figure 6).
Identifying these patients allows primary care teams to immediately refer them to PCBH clinicians, community resources, and the on-site ARISE IPV Advocate. As of June 30, 2019, the IPV advocate had met with 192 patients. Prior to ARISE, few patients who disclosed IPV reported connecting with a community-based IPV agency after being referred. In the first 28 months after ARISE was established, 40% of patients who met with the ARISE IPV Advocate after a “warm hand-off” attended at least one follow-up visit at the community drop-in center at La Casa de las Madres. Research suggests that accessing such resources improves safety and reduces IPV and that incorporating these resources into the health care setting improves IPV screening and disclosure rates.
A “trauma-informed system” has been defined as one that “realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.” The BHVS is a key innovation that highlights, for patients and health care staff, that relationships and experiences are key determinants of health. By incorporating not only IPV, depression, and substance use but also coping strategies and resilience factors, the BHVS provides hope for healing. Implementing and prioritizing the BHVS as a key component of ARISE’s overall trauma-informed systems-change has driven widespread trauma-informed care and IPV training, improved primary care behavioral health integration, supported the growth of a health care-community based IPV organization partnership, and, ultimately, made our health care system more healing.
In most health care systems, including the SFHN, IPV disclosure rates remain lower than the IPV prevalence observed in research studies. Preliminary results of the ARISE evaluation in the subset of 56 patients who volunteered for the evaluation demonstrate that only 48% of the female-identified patients who had experienced IPV by an intimate partner in the past 12 months reported previously disclosing IPV to their health care provider, for a wide variety of reasons. Primary care and behavioral health clinicians may not be aware of the discrepancy between IPV prevalence and IPV disclosure, risking false reassurance after a negative screen and potentially preventing clinicians from providing patients with the universal education (UE) about IPV taught by ARISE.
Patients may dislike tools like BHVS or not recognize or want to discuss the interconnectedness of behavioral conditions with their symptoms and concerns. Patient advisors expressed preference for screening tools that include items regarding positive coping behaviors and resilience factors (which are included but currently not routinely entered into the EHR via standardized fields.)
“You people have all these [screening tools] that you want me to fill out that have nothing to do with why I came in for my visit,” Patient Advisory Board Member, San Francisco Health Network.
Without robust behavioral health resources or effective care models for follow up, health care providers understandably can have mixed feelings about BHVS screening. Additionally, patients may express reluctance to engage with PCBH due to stigma and other concerns, even if those services are available. As an example, a current resource limitation in our system is that positive responses to the BHVS do not lead to screening for post-traumatic stress disorder (PTSD), despite the high prevalence of PTSD in safety net populations and patients who have experienced IPV (especially sexual violence). Our work should serve as a call to action to generate more comprehensive evidence on models that concurrently address IPV and co-occurring behavioral health conditions in primary care settings.
- Enrichment of our universal education (UE) approach to ensure that all patients, regardless of disclosure, are given education about trauma and resilience, the impacts of IPV, depression, substance use, and other mental health conditions on well-being and health, and available clinic and community resources. ARISE has developed new UE tools including four animated videos and a printed educational tool about caregiver-child relationships and the inter-generational impacts of IPV, trauma, stress, resilience, and coping, called “Together We Can Heal,” that we plan to implement and evaluate.
- Enhanced focus on coping behaviors and resilience factors through (1) provider training on how to incorporate discussion of coping and resilience into clinical encounters; (2) creation of standard work that includes communication about coping and resilience between PCP and PCBH; (3) EHR documentation of the coping behaviors and resilience factors found on the BHVS; and (4) evaluation of the impact of addressing coping and resilience in clinical encounters on patients and providers.
- Development, implementation, and evaluation of behavioral health treatment models that effectively and concurrently address IPV and co-occurring substance use and other mental health conditions, including PTSD, in adolescents and adults. We also plan to explore how to effectively mitigate the impact of these conditions in adult caregivers on children, so as to prevent the intergenerational transmission of trauma and its myriad associated adverse effects.
The authors would like to thank Amanda Rodriguez, MPH, Allison Ipsen, Ashley Scarborough, MPH, Radawn Alcorn, MSW, LCSW, the Primary Care Behavioral Health Quality Improvement Committee, our Patient Advisory Board Members, and our dedicated SFHN safety-net health care staff, La Casa de las Madres, the Trauma Recovery Center, BayLegal, and Futures without Violence.