Improving Screening and Referral for Violence Against Women: Interpersonal Violence and Adverse Childhood Experiences

This project has an overall goal of improving screening and referral for violence against women, and specifically targets intimate partner violence (IPV) and adverse childhood experiences (ACE). In 1995, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of ten of the leading causes of death in the United States. That exposure is toxic stress caused by various ACEs. Those who are exposed have triple the lifetime risk of heart disease and lung cancer, increased rates of obesity, diabetes, preterm labor, low birth weight, unplanned pregnancy, chronic pelvic pain, vaginismus, vaginitis, depression, PTSD, impaired sexual function, and increased perception of pain in labor. However, many Utah midwives and nurse practitioners are not trained in appropriate assessment or management of ACE survivors. This is problematic, as over half of Utahans have experienced at least one ACE. In addition to ACEs affecting the health of women, IPV leads to worsened health outcomes and increased healthcare costs. Furthermore, one in three women in Utah will be victims of rape, physical violence, or stalking by an intimate partner at least once in their lifetime. Despite the prevalence of IPV and ACEs, midwives at a national and local level are not following ACOG guidelines for IPV screening, which state to screen at the new obstetrical visit, every trimester, and postpartum, nor are they assessing ACE scores or resiliency. Helping an individual develop resiliency traits is the hallmark of ACE intervention, and local mental health providers in Utah are trained to do so. However, healthcare providers are mostly unaware of such interventions. Therefore, the objectives of this project include obtaining knowledge of IPV, ACEs, screening tools, questionnaires, and recommendations for positive screens; implementing an IPV screening tool into new obstetrical and postpartum visits within a large midwifery practice in Utah; implementing an ACE assessment in this same practice; and providing midwives and nurse practitioners with resources for responding to a positive or negative screen. The HARK screening tool was used to screen for IPV. To assess ACEs and resiliency, the Health-Resiliency-Stress-Questionnaire (HRSQ) was built into and distributed via mEVAL, a patient-reported outcome email system for all seven clinics within this practice. Over 30 trauma-informed counselors were identified, and healthcare providers were given this information in addition to other resources for referral and follow-up for positive screens. Overall, the goal for IPV screening was to implement a validated IPV screening tool to allow prevention strategies to take place and to provide the woman with resources to improve her health and safety. For ACE assessment, the goal was to increase provider awareness of patients' ACE score as it relates to their medical history and resiliency traits, provide appropriate referral resources to promote treatment for positive scores, and identify local resources that can help with toxic stress.

1 Running head: IPV AND ACES Improving Screening and Referral for Violence Against Women: Interpersonal Violence and Adverse Childhood Experiences Emily S. Miller, RN, BSN, SNM, SWHNP University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice IPV AND ACES 2 Executive Summary This project has an overall goal of improving screening and referral for violence against women, and specifically targets intimate partner violence (IPV) and adverse childhood experiences (ACE). In 1995, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of ten of the leading causes of death in the United States. That exposure is toxic stress caused by various ACEs. Those who are exposed have triple the lifetime risk of heart disease and lung cancer, increased rates of obesity, diabetes, preterm labor, low birth weight, unplanned pregnancy, chronic pelvic pain, vaginismus, vaginitis, depression, PTSD, impaired sexual function, and increased perception of pain in labor. However, many Utah midwives and nurse practitioners are not trained in appropriate assessment or management of ACE survivors. This is problematic, as over half of Utahans have experienced at least one ACE. In addition to ACEs affecting the health of women, IPV leads to worsened health outcomes and increased healthcare costs. Furthermore, one in three women in Utah will be victims of rape, physical violence, or stalking by an intimate partner at least once in their lifetime. Despite the prevalence of IPV and ACEs, midwives at a national and local level are not following ACOG guidelines for IPV screening, which state to screen at the new obstetrical visit, every trimester, and postpartum, nor are they assessing ACE scores or resiliency. Helping an individual develop resiliency traits is the hallmark of ACE intervention, and local mental health providers in Utah are trained to do so. However, healthcare providers are mostly unaware of such interventions. Therefore, the objectives of this project include obtaining knowledge of IPV, ACEs, screening tools, questionnaires, and recommendations for positive screens; implementing an IPV screening tool into new obstetrical and postpartum visits within a large midwifery practice in Utah; implementing an ACE assessment in this same practice; and providing midwives and nurse practitioners with resources for responding to a positive or negative screen. The HARK screening tool was used to screen for IPV. To assess ACEs and resiliency, the Health-Resiliency-Stress-Questionnaire (HRSQ) was built into and distributed via mEVAL, a patient-reported outcome email system for all seven clinics within this practice. Over 30 traumainformed counselors were identified, and healthcare providers were given this information in addition to other resources for referral and follow-up for positive screens. Overall, the goal for IPV screening was to implement a validated IPV screening tool to allow prevention strategies to take place and to provide the woman with resources to improve her health and safety. For ACE assessment, the goal was to increase provider awareness of patients' ACE score as it relates to their medical history and resiliency traits, provide appropriate referral resources to promote treatment for positive scores, and identify local resources that can help with toxic stress. Content experts for this project include Susan Chasson, MSN, JD, FNP, CNM, SANE coordinator and Kathy Franchek, MD as they both serve on various IPV committees and have directly influenced IPV prevention, screening, and treatment in Utah. Further, Dr. Franchek is a pediatrician and is well versed in the ACE study, and Susan Chasson currently practices with adult populations. Committee experts include project chairs Amanda Al-Khudairi, DNP, WHNP-C and Diane Chapman, DNP, FNP-C, program sponsor and specialty track director Gwen Latendresse, PhD, CNM, FACNM, and assistant dean for MS & DNP programs Pam Hardin, PhD, RN. IPV AND ACES Table of Contents Title Page………..……………………………………………………………………………1 Executive Summary…………………………………………………………………………..2 Table of Contents..……………………………………………………………………………3 Problem Statement……………………………………………………………………………5 Clinical Significance and Policy Implications………………………………………………..6 Purpose and Objectives……………………………………………………………………….8 Literature Review……………………………………………………………………………..9 Theoretical Framework………………………………………………………………………19 Objectives, Implementation, and Evaluation…………………………………………………21 DNP Essentials………………………………………………………………………………..29 References…………………………………………………………………………………….30 Appendices……………………………………………………………………………………33 Appendix A [Health-Resiliency-Stress-Questionnaire (HRSQ)]……………………..33 Appendix B [HARK tool for Interpersonal Violence screening in EPIC]……………35 Appendix C [Defense Powerpoint]…………………………………………………...36 Appendix D [Birthcare Healthcare Provider Meeting Presentation]………………..39 Appendix E [Trauma-Informed Provider List]……………………………………….43 Appendix F [HRSQ scoring] …………………………………………………………46 Appendix G [HRSQ Suggested Responses + Helpful Links] …………………………47 Appendix H [IPV University of Utah Policy Algorithm] ……………………………..49 Appendix I [IPV Resource Page for EPIC] …………………………………………..50 Appendix J [Screening Frequency Reminder Cards] ………………………………...51 3 IPV AND ACES Appendix K [Defense Poster] …………………………………………………………52 4 IPV AND ACES Improving Screening and Referral for Violence Against Women: Interpersonal Violence and 5 Adverse Childhood Experiences Violence against women occurs in various ways and at various times in a woman's life, often through interpersonal relationships or during childhood through adverse experiences. Both interpersonal violence and adverse childhood experiences are highly prevalent among American women and both contribute significantly to health outcomes, healthcare costs, and overall functioning. One in three women in the United States have been victims of rape, physical violence, or stalking by an intimate partner at least once in their life time (ACOG, 2012), and more than half (63.1%) of Utah adults report being ACE survivors. Despite the prevalence of IPV and ACEs, midwives at a national and local level are not following ACOG guidelines for IPV screening, nor are they implementing ACE assessments even with ample evidence about its importance and the availability of effective interventions. The same issue applies to a nursemidwifery practice in Salt Lake City, UT, where providers are not assessing for ACEs or resiliency, and there is no standardized and consistent use of an IPV screening tool. Furthermore, IPV is only screened at the new obstetrical visit at this clinic. This project aims to improve screening, provide women's health providers at Birthcare Healthcare, a local nurse-midwifery practice, with resources for positive screens, and enhance the health and safety of women in Utah. By incorporating an ACE assessment tool into new obstetrical and annual visits, integrating a validated IPV screening tool into the EMR, and developing a web resource page for providers, midwives have an incredible opportunity to identify patients who would benefit from counseling, interventions for an unsafe environment, education on the effects of IPV or ACEs, and improved health outcomes. 6 IPV AND ACES Clinical Significance and Policy Implications Clinical Significance If midwives do not assess for IPV and ACEs appropriately, women may go without the help they need. IPV has been linked to poor pregnancy weight gain, infection, anemia, stillbirth, fetal injury, and preterm delivery, and ACEs are associated with negative health behaviors and adverse birth experiences (ACOG, 2012). Conversely, if appropriate and more frequent screening does occur, more women may disclose IPV or ACE history than they would if only asked once or not at all (ACOG, 2012). Research has shown that interpersonal violence is more prevalent in women who are assessed in all three trimesters when compared to only once during the first prenatal appointment as is current practice at Birthcare Healthcare (Alhusen, Ray, Sharps, & Bullock, 2015). In addition to increasing identification of those at risk, screening also provides an opportunity to halt the cycle of abuse, offer ongoing support, and provide referral to appropriate resources. It is known that pelvic examinations may be associated with terror and pain for survivors, and they may re-experience powerlessness, violation, and fear. If a woman has a history of abuse or adverse childhood experience, providers may follow recommendations more closely for explaining procedures in advance, adhere to new guidelines on when to perform a bimanual examination, and provide techniques to lessen anxiety and fear around obstetrical exams and procedures if they identify a positive screen ahead of time (ACOG, 2015). Finally, LoGiudice & Beck (2016) discuss the need for initiation of trauma-informed care, and they recommend the first step to implementing this type of care is to ask women if they are survivors or victims of past or current interpersonal violence and adverse childhood experiences. IPV AND ACES 7 Stakeholders Stakeholders in this project include midwives, pregnant women, families and children of pregnant women, the unborn child, labor and delivery staff, postpartum staff, obstetricians, and mental-health professionals. Midwives are in a unique position to assess and give support to those who experience abuse, past or present, due to the nature of obstetrical care with several opportunities to screen and intervene over the course of a pregnancy (ACOG, 2012). Abuse survivors may seek out midwives, such as those employed with Birthcare HealthCare, in Salt Lake City, Utah, so they can have more control over their birth experience (LoGiudice & Beck, 2016). Pregnant women are key stakeholders in this change project. According to Friedrichs (2015), more than half of Utah's population reported experiencing ACEs, and the severity of interpersonal violence may escalate during pregnancy or the postpartum period (ACOG, 2012). Also, homicide is a leading cause of maternal mortality with the majority of homicides being perpetrated by a current partner (ACOG, 2012). Up to 40% of children in the United States experience some form of childhood sexual abuse, and many do not disclose their experience until later in life (ACOG, 2015). However, ACOG (2015) reports that women support a universal inquiry about sexual assault, because they may have reluctance to initiate the discussion. Lastly, the family unit is affected due to the destructive effects on family members and children with adverse pregnancy outcomes related to sexual abuse (past or present), the loss of financial or emotional stability with intimate partner violence, or toxic stress from childhood trauma (ACOG, 2012). These detrimental effects can lead to increased populations of homeless women and children (ACOG, 2012). Mental health professionals are primary stakeholders, as 8 IPV AND ACES they will receive referrals from obstetric providers who identify women in need of IPV and ACE counseling (ACOG, 2015). Purpose and Objectives The purpose of this project is to improve screening of intimate partner violence (IPV) and assessment of adverse childhood experiences (ACE) and resiliency within a midwifery practice in Salt Lake City, Utah. Furthermore, this project aims to educate providers on how and why to assess for these experiences, provide referral options to women who screen positive, and offer providers resources for a positive screen for IPV or poor resiliency with a history of childhood trauma. The following objectives serve to meet this purpose: 1. Obtain knowledge regarding significance of IPV, ACEs, existing screening tools and assessments, and recommendations for positive screens 2. Identify sponsor to "pitch" project to midwifery practice 3. Implement evidence-based IPV screening tool and ACE questionnaire into practice 4. Provide practitioners with resources on how to respond to positive IPV and ACE assessments 5. Disseminate results. Literature Review Studies demonstrating the correlation between poor health outcomes and IPV and ACEs highlight the need to screen or assess women for both IPV and ACEs to better improve women's health and newborn outcomes (ACOG, 2015). Specifically, providers should be looking at both present and past abuse. Nationally and locally in Utah, women have a high prevalence of IPV and ACEs, and midwives have an incredible opportunity to intervene when screening women for both types of adversity due to the nature and the frequency of prenatal visits. Furthermore, IPV AND ACES providers need more education on how to screen for IPV and ACEs, what to do with a positive 9 screen, and what screening tool to utilize (Eustace, Baird, Salto, & Creedy, 2016). If midwives can improve their ability to detect women who have experienced ACEs or IPV, midwives can greatly improve health and pregnancy outcomes. Search Methods A search about interpersonal violence, adverse childhood experiences, resiliency, and methods of intervention for those affected was done using PubMed, CINAHL, and the Cochrane Library Database. Keywords included ACEs, adverse childhood experiences, resiliency, resiliency traits, trauma-informed care, interpersonal violence, domestic violence, past abuse, childhood abuse, childhood adversity, promoting resiliency, IPV, IPV screening, IPV screening tools, ACE questionnaire, ACE screening tool, violence against women, and pregnancy. Research studies were limited to those published in the English language with full-text, human subjects, and the last 17 years from 2000-2017 to reflect the most comprehensive review of literature on violence against women. Committee opinions from national, professional organizations were included to reflect the most current practices and stances on interpersonal violence and childhood trauma. Additional information was garnered from the CDC's Brief Surveillance Report. Background Defining Abuse and Resiliency Interpersonal violence has been defined as behavior within a relationship that either causes physical, sexual, or psychological harm, and this can be perpetrated by either a former or current partner (Eustace, Baird, Salto, & Creedy, 2016). The United States Preventative Services Task Force (USPSTF) describes IPV as above, but adds that this can occur among both IPV AND ACES 10 heterosexual or same-sex couples, all races and genders, and it does not require intimacy (Moyer, 2013). Adverse childhood experiences were the center of a study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente that focused on the outcomes of trauma on the developing brain and health across the life span. Dr. Felitti, key researcher in the ACE study, included over 17,000 patients, who were mostly white, educated, middle-class, and insured. Over the past few decades, researchers have discovered three areas of the brain that are negatively affected by trauma as a child due to the overstimulation of the hypothalamic-pituitaryadrenal axis (HPA). The areas affected include the nucleus accumbens which is the brain's pleasure and reward center, the prefrontal cortex that is necessary for impulse control and executive functioning, and the brain's fear center, the amygdala (Burke, 2014). Damage to these areas may be directly linked to increases in substance abuse, multiple sex partners, obesity, and increased pain and fear in labor (Burke, 2014). Adverse childhood experiences include any childhood verbal, physical, and sexual abuse, parental neglect, parental substance abuse, divorced or separated parents, domestic violence of a parent, mentally ill family member, family member in prison, or a family member who attempted suicide (Redding, 2016). One simply cannot discuss adverse childhood experiences without discussing the idea of resiliency, as helping an individual develop resiliency traits is the hallmark of improving lives of ACE survivors. Resiliency is considered to be the individual's ability to successfully adapt to life tasks in the face of social disadvantage or adverse events, and a resilient person is able to create an acceptance of reality, believe life is meaningful, manage adversity, and push through hardships (Luthar, 2000). Further, unrecognized and unresolved ACEs can continue to impact neurobiological changes that influence health, but when a person becomes resilient, it helps them IPV AND ACES 11 stop the cycle of the HPA overstimulation. Halting this maladaptive cycle can result in increased life success, higher academic achievement, less health problems, and utilization of less medication (APA, 2014). Resiliency is not developed overnight, but it involves behaviors, thoughts, and actions that can be learned by anyone. Trauma-informed counselors are trained in methods such as eye movement desensitization and reprocessing (EMDR) and trauma-based cognitive therapy that have been shown to improve a person's resiliency traits and lead to better health (APA, 2014). Prevalence and Cost More than half (63.1%) of Utah's adult residents are ACE survivors (Friedrichs, 2015). In the 2013 Utah Behavioral Risk Factor Surveillance System (BRFSS), researchers indicated that both direct (physical, sexual, or verbal) and environmental sources (exposure to mental illness, substance abuse, divorce, incarceration, or witnessing abuse) were associated with risky behaviors and poor health outcomes (Friedrichs, 2015). Nationally, it is estimated that 12-40% of children experience a form of childhood abuse, yet shame prevents many from reporting so the actual prevalence may be higher (ACOG, 2015). Approximately 1 in 5 women have experienced childhood sexual abuse, which is one of the most significant ACEs in terms of healthcare outcomes (ACOG, 2015). It is known that adult ACE survivors disproportionately utilize health care services, resulting in higher health care costs when compared to adults who have not had such experiences (ACOG, 2015). Moyer (2013) noted that almost 31% of women report having experienced IPV in their lifetime, yet these rates are most likely lower than the actual rate due to underreporting. The World Health Organization reported that one in three women globally have been physically or sexually abused by a partner (WHO, 2013). Due to the amount of women affected by IPV, IPV AND ACES Kottenstette & Stulberg (2013) note this prevalence results in almost two million injuries to 12 women and over four billion dollars in medical and mental health costs. Also, there is a reported incidence of IPV of one in six pregnancies for adult women and one in five pregnancies for teens (Anderson, Marshak, & Hebbeler, 2002). Outcomes Physical and Psychological The health outcomes of IPV and ACEs are significant and both can result in a number of negative effects later in life. The authors of the ACE study discuss extensively the pathophysiology behind the altered stress response when a child experiences an ACE. When this occurs, it can alter the life of the child leading to physical effects such as chronic pain, abdominal and pelvic pain, lower pain threshold, and increased rates of obesity, eating disorders, substance abuse, stroke, and diabetes (ACOG, 2015). Adults who have experienced ACEs or IPV can have sexual disturbances related to impaired desire, arousal, and orgasm, and they may be more likely to have multiple sexual partners and sexually transmitted infections. Other gynecologic outcomes include unintended pregnancy, chronic pelvic pain, dyspareunia, vaginismus, nonspecific vaginitis, and less likelihood of complying with recommendations for cervical cancer screening and prenatal care (ACOG, 2015). Women who have experienced IPV can experience more neurologic disorders and migraines, and they are more likely to be revictimized by others. Psychological effects on victims of ACEs or IPV include depression, posttraumatic stress disorder, anxiety, substance abuse, suicidal behavior, and poor self-esteem (Moyer, 2013). Even with the knowledge of the varied impacts of IPV and ACEs, identifying the underlying cause of the wide array of symptoms with which women present can be challenging for providers. Because of this challenge, obstetrician-gynecologists and midwives IPV AND ACES should routinely screen for childhood sexual abuse and IPV, be able to recognize disease 13 processes that are a potentially a result of violence or adversity, and provide referral and support as appropriate (ACOG, 2015). Pregnancy Outcomes In addition to the physical and psychological effects listed above, pregnant women who have experienced ACEs or IPV, are more likely to experience preterm birth (up to 20% more), low birth weight, depression, anxiety, teen pregnancy, unintended pregnancy, and suicidal ideation in pregnancy (ACOG, 2015). Not only are these outcomes more likely to occur, but the prenatal visit and birth themselves can trigger symptoms of fear, shame, humiliation, guilt, selfblame, and recurring thoughts of the past abuse. Pregnant women also experience an increased perception of pain in labor if they have a high ACE score. Also, victims may begin to believe they caused or deserved the abuse (ACOG, 2015). IPV AND ACES Screening 14 There is a universal understanding among professional organizations that it is important for women's health providers to screen for IPV. The USPSTF conducted a systematic review on IPV screening that examined the accuracy of screening tools for identifying IPV as well as the benefits and harms. Their conclusion is that clinicians should screen women of childbearing age for IPV, and provide or refer women who screen positive to intervention services (Moyer, 2013). They rank this as a B recommendation, and advise these recommendations be applied to asymptomatic and symptomatic women of reproductive age (14-46 years old) (Moyer, 2013). A B recommendation is given when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial (USPSTF, 2012). The Institute of Medicine (IOM) and American Congress of Obstetricians & Gynecologists (ACOG) also supports this recommendation, but ACOG specifically recommends screening routinely at preconception, family planning, and gynecology visits as well as every trimester and postpartum visit (Anderson, Marshak, & Hebbeler, 2002). Further support for routine screening for IPV in healthcare settings was also identified in a recent Cochrane review which concluded that routine screening increased the identification of IPV, but rates were still below prevalence estimates of IPV in all women seeking healthcare (Eustace, Baird, Salto, & Creedy, 2016). Anderson, Marshak, & Hebbeler (2002) suggest that using a validated tool for IPV screening is the only way to assess accurately for interpersonal violence. The USPSTF's systematic review of IPV screening concluded that there is adequate evidence to support that validated instruments help identify individuals with current and past abuse or increased risk for abuse (Moyer, 2013). They also report that several screening tools can be used, but those with the highest levels of sensitivity and specificity for IPV include Humiliation, Afraid, Rape, and IPV AND ACES Kick (HARK), Hurt, Insult, Threatened with Harm, and Screamed (HITS), Ongoing Abuse 15 Screen (OAS), Ongoing Violence Assessment Tool (OVAT), and Women Abuse Screening Tool (WAST) (Moyer, 2013). While ACOG recommends every trimester for IPV screening, the USPSTF found no evidence on appropriate intervals for screening once a tool is selected (Moyer, 2013). While guidelines and recommendations for ACE screening are evolving, Corwin et. al, (2015) explain that assessing for ACEs is intended to uncover past experiences and major stressors so providers can intervene and give support that may have been overlooked. Also, the authors highlight that data from the Kaiser ACE study suggest that an important way to help providers gain a holistic view of an individual's health is to screen for ACEs and understand their exposure (Corwin et. al, 2015). In addition to adequate research on the physiological effects, cost, and prevalence of ACEs, there are other benefits for the actual screening process of both IPV and ACEs. The USPSTF found that effective interventions for a positive screen can reduce violence, abuse, physical harm, or mental harm for women of reproductive age (Moyer, 2013). Kottenstette & Stulberg (2013) report that prenatal behavioral counseling by psychologists or social workers led to decreased IPV and improved birth outcomes such as reduced preterm birth, increased mean gestational age, and decreased rates of low birth weight. The authors also note screening and referral for counseling when compared to usual care lead to decreased pregnancy coercion, which is described as being physically threatened with pregnancy or prevented from contraception (Kottenstette & Stulberg, 2013). There are few, if any, adverse effects for IPV or ACE screening, and the USPSTF found adequate evidence that the risk for harm to the individual from screening or interventions is no IPV AND ACES greater than the risk of violence (Moyer, 2013). Reported consequences of screening may 16 include loss of privacy, emotional distress, and concerns about further abuse, but women report feeling valued when asked about violence (Kottenstette & Stulberg, 2013). ACOG (2015) advises that not asking about violence may give additional support to the victim's belief that abuse does not matter and does not have medical relevance. Resources and Best Care Appropriate screening must be completed before providers can consider the need for referral or interventions. Prior to screening, the provider should make sure the patient is alone and make sure they are aware of what has to be reported by law. When screening, providers should make the questions seem natural, normalize the experience by giving facts about the commonality of violence, give the patient control over what and when she discloses information, ask if she has disclosed it before or sought help, listen attentively, and know that the physical exam can be postponed to address violence (ACOG, 2015). There are various interventions for women who screen positive such as counseling, home visits, information cards, referrals to community services, and mentoring support, and these interventions may be provided by providers, nurses, social workers, or community workers (Moyer, 2013). Furthermore, providers should not screen for IPV or adverse childhood experiences until reliable procedures and resources for follow-up or intervention for positive screens have been identified (Kottenstette & Stulberg, 2013). ACOG (2015) recommends that providers compile a list of experts with experience in abuse and have crisis hotline numbers for IPV readily available. ACOG (2015) highlights the need to normalize interventions and suggests that appropriate scripting might include something like, "I would like Dr. X to assess you to determine if your past abuse is contributing to your current health problems." In addition to IPV AND ACES having resources for referrals, providers should be aware of state and local reporting laws, as 17 these vary from one jurisdiction to another (Moyer, 2013). In order to remain efficient, providers need easy access to available tools, specific guidelines, and other related materials to help them develop a clinical environment dedicated to the safety of their patients (Moyer, 2013). While the USPSTF recommends the women's health care provider's role is simply to identify, report if needed, and refer to appropriate resources, there are other interventions or best practices providers can follow to provide trauma-informed care. ACOG (2015) reports that pelvic examinations may be associated with terror and pain, and feelings of vulnerability arise in the lithotomy position leading the survivor to re-experience past feelings of powerlessness, violation, and fear. Therefore, guidelines for when to provide physical exams and procedures should be adhered to and performed when medically necessary, providers should be equipped to provide compassionate and patient-centered care, and patients should receive anticipatory guidance for the possibility of the previously mentioned feelings and fears arising (ACOG, 2015). Lastly, the patient may want family or friends present, and she should know that she has the right to stop any time. The patient may also desire eye contact, a mirror to see the pelvic exam, and slower examinations (ACOG, 2015). Common Barriers to IPV and ACE screening Even when screening and intervention is agreed upon among providers in a particular practice, there are always barriers to change. Some studies highlight barriers to screening include inability to incorporate tools into practice, lack of education and training on screening and treatment or referral, feeling inadequately prepared to deal with positive screens, inability to develop rapport on initial visit and fear that asking sensitive questions will impair the relationship, and the lack of a multidisciplinary team to address violence (Eustace, Baird, Salto, IPV AND ACES & Creedy, 2016). Despite these potential barriers, Anderson, Marshak, & Hebbeler (2002) 18 report many women will talk openly if given a chance, women want health care providers to ask about violence although they reported the desire for confidentiality and support, and patients favor inquiry as they report a reluctance to initiate a discussion of the subject. Furthermore, research suggests pregnant women are comfortable disclosing sensitive personal information with midwives, as they believe their relationship with their midwife to be safe, supportive, and professional, but many midwives do not feel comfortable asking about or managing women who disclose IPV (Eustace, Baird, Salto, & Creedy, 2016). In regards to inability to screen due to logistics of clinic layout and time, there was a feasibility study published in 2016 that involved nurses administering an ACE questionnaire to patients in a family practice clinic, and they noted there were high rates of ACEs, only a couple minute increase to the visit, new insight for the patient into their overall health, a high success rate, and 100% of the staff felt it did not interfere with the visit (Glowa, Olson, & Johnson, 2016). Also, 98% of the staff felt it was acceptable to the patient from the staff member's perspective (Glowa, Olson, & Johnson, 2016). A multidisciplinary approach is necessary to effectively implement ACE and IPV screening. Provider training, access to resources, technological advancements, and patient education are all facilitators to the process (Eustace, Baird, Salto, & Creedy, 2016). Eustace et. al (2016) further state that asking the screening questions alone is not enough, and midwives need to feel knowledgeable and confident in their abilities to respond to women who disclose current or past abuse. IPV AND ACES Theoretical Framework 19 The ACE Star Model of Knowledge Transformation is applicable for this project as it guides the implementation of existing research into clinical practice (Stevens, 2012). The major stages of the model include discovery or research, evidence summary, translation to guidelines, practice integration, and outcome evaluation. Traversing these stages of the model will enable a practitioner to utilize a framework for systematically putting evidence-based practice into operation. The first stage of discovery or research is where new knowledge is discovered through traditional research methods and inquiry (Stevens, 2012). The first stage of the interpersonal violence (IPV) and adverse childhood experiences (ACE) screening project involved a comprehensive search among databases to determine the prevalence of IPV and ACEs, as well as the clinical significance, recommendations, and health outcomes. Secondly, an evidence summary, or a literature review, was completed in order to synthesize the vast amount of knowledge that exists on the topic of ACEs and IPV. The advantages of producing such a literature review before implementation include reducing large quantities of information into a manageable medium, assessing consistencies and inconsistencies in the literature, and reviewing future research implications (Stevens, 2012). Next, this DNP project incorporated the third stage of the ACE Star Model, translation to guidelines, by reviewing current professional organizations, such as the American College of Obstetricians & Gynecologists (ACOG), to have a guide in implementing the evidence into practice. After guidelines were reviewed, a process of practice integration was developed. This included working with key stakeholders at Birthcare Healthcare to build an existing screening IPV AND ACES tool into an electronic system, discuss a pilot of the screening method, and determine usability 20 within the electronic medical record. Finally, there was an evaluation of the assessment interventions by conducting chart reviews in order to determine if the screening was occurring. By using this model, the goal of this project was carried out by transforming knowledge into an evidence-based quality improvement project. Objectives, Implementation, and Evaluation Before any of this project could be carried out, knowledge needed to be obtained regarding the significance and prevalence of interpersonal violence (IPV) and adverse childhood experiences (ACE) for women, which screening tools are evidence-based or validated, and what therapies or referrals are recommended for women who have a positive screen. To achieve this objective, a thorough literature review was completed that summarized national guidelines on screening, prevalence and significance of IPV and ACEs, barriers and facilitators to screening, and the health outcomes that are affected by IPV and ACE. The literature review was submitted to the project chair and content experts for review, and feedback was given to identify gaps in knowledge and recommendations for further exploration. To accomplish the objective of improving IPV screening and implementation of ACE and resiliency screening, a sponsor for the practice site was identified for implementation. This sponsor helped facilitate discussion of this project at a provider meeting, recruited inside support for the project, and provided feedback on implementation strategies. The practice sponsor was Gwen Latendresse, who is also the program director of the certified nurse-midwifery program at the University of Utah. An IRB application was submitted, but it was ultimately exempt from IRB oversight.. IPV AND ACES Initially the primary goal for IPV screening was to implement an evidence-based tool, 21 such as the two-question screening tool into existing EPIC notes or "smart text"; however, this was ultimately changed to the current University of Utah-approved IPV screening tool, the HARK tool, as it is hospital policy and already existed in the charting system used by the practice. Further, designing a unique smart text can take several months for the EPIC department to create, and the midwifery practice has additional changes to incorporate into this new EPIC smart text that were not yet decided upon at the time of implementation of this project. Nonetheless, despite the tool's existence in the system and current policy, the HARK tool was not being used. Therefore, an overview of the tool, how to access it, and the suggested frequency of screenings was presented to the practice at a monthly provider staff meeting. The midwife and medical assistant's daily workflows were taken into consideration, and screenshots of exactly how one should access the tool were presented in the PowerPoint presentation. After meeting with Kristan Warnick, LPC and Susie Wiet, MD, local psychiatrists and founders of the trauma resiliency collaborative in Utah, I decided to use Dr. Wiet's HRSQ tool rather than the simple ACE questionnaire, as the latter does not include resiliency assessment. It should be noted that the decades of research of association between toxic stress and adverse health outcomes have come from Dr. Felitti's original ACE questionnaire, which has not been validated given the length of time and amount of variables involved in determining improvement in chronic health status. Therefore, Dr. Wiet's innovative HRSQ tool, that is currently in the final stages of a validation study, paved the way for midwifery providers to begin discussing ACEs, toxic stress, and developing resiliency. Dr. Wiet's tool includes four parts, two of which are validated screening tools. The first section (Part A) includes two parts. Part A-1 of the HRSQ is the Brief Resilience Scale (BRS), a validated resiliency tool that was originally studied IPV AND ACES 22 among mostly young to middle-aged females in the United States that was shown to have good internal consistency and test-retest reliability (Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008). Further, the BRS is the only tool to evaluate resiliency as the ability to bounce back or recover from stress. Part A-2 includes eight questions, put together by Dr. Wiet, to assess attachment and other protective factors that are not currently asked on other resiliency assessments. Part B includes a basic health assessment in order to gain an understanding of how the patient perceives his or her mental and physical health. Part C includes the validated PCPTSD post-traumatic stress disorder screening tool. Lastly, Part D is the original ACE questionnaire from the Kaiser study with a few additional questions about ACEs that were added by Dr. Wiet. The HRSQ was designed to give primary care providers a quick overview of a person's ability to tolerate and cope with stress in relationship to their health and past traumatic experiences. Further, it is designed to stratify the ratio of resiliency traits to the expanded ACE score to produce an HRSQ risk-category that will be able to drive targeted intervention. It is an efficient, self-administered tool that takes approximately 2-5 minutes to complete. The validation study population includes 132 patients, mostly young to middle-aged females, who were screened in mostly primary care clinics. Other practices included in the validation study included pediatrics (mothers at the four-month well-child visit), internal medicine, addiction residential treatment center, outpatient psychiatry, and outpatient therapy. In order to distribute the tool, the Health-Resiliency-Stress-Questionnaire (HRSQ) was built by university IT personnel and placed in the mEVAL electronic email system, so that the tool could be emailed to all new patients and updated yearly. Parts A-C will be asked annually, and Part D is asked once in a lifetime. This development took a handful of meetings and phone calls to discuss details of frequency of screening, how scoring should be displayed, who will be IPV AND ACES responding to the results. IT met with their medical expert to verify its utility in the medical 23 setting. mEVAL was chosen as providers at Birthcare Healthcare were already using this system for other screening tools for their patients. To evaluate this objective, I initially desired a twomonth pilot period in order to do chart reviews to show how many patients were doing the screening and to determine barriers. However, this was when we were anticipating paper screening for ACEs. When it was discovered that having the HRSQ placed in the mEVAL system was very tangible after previously thinking it would take over a year and require all OB providers to sign off on its use, I knew this was an extremely beneficial change to make. However, this change to use mEVAL caused some delay in getting a two-month period of chart reviews, so only the first week of implementation was assessed. The bigger goal that was accomplished with this electronic system was providing sustainability in the practice even after this project is over, as the tool is a permanent adaptation to Birthcare Healthcare's mEVAL use. Screening alone will not improve the health of women, as providers need to know how to respond to positive screens. Therefore, a key objective of this project was providing the midwives and practitioners adequate resources to respond to positive IPV and ACE screenings. Originally, I planned to create an algorithm for responding to IPV, but this was already designed by Dr. Kathy Franchek (content expert) and her domestic violence committee at the University of Utah. This includes a 100-page document detailing IPV reporting laws, ICD-10 codes, appropriate algorithms for response to vulnerable adult abuse, child abuse, sex trafficking, and interpersonal violence, as well as local resources for victims. This document was placed on the "PULSE" website for the midwifery practice to access at all times in a Birthcare Healthcare "Childhood Abuse and IPV" specific folder. Further, the one-page IPV algorithm was laminated and placed in all clinics. Commented [DC1]: IUPV or IPV? IPV AND ACES 24 In order to help providers respond to the HRSQ screen, I met with several mental health professionals in the area and emailed over 50 providers to see who would be willing to see the midwives' patients for high scores. I created a document with over 30 trauma-informed mental health professionals and clinics that are either trained in EMDR or other trauma-focused therapies. Insurance information, wait times, languages spoken, and other therapies offered were included in the document, and this was placed on PULSE with the IPV resources. This was done due to feedback from University of Utah College of Nursing faculty about having enough resources for uninsured patients. Lastly, helpful links, HRSQ scoring, and suggested responses to various HRSQ risk levels were included on PULSE and discussed at the provider meeting. A summary of the literature review and pilot screening period with results was included in an abstract for dissemination. It was accepted for a poster presentation at a local American College of Nurse-Midwives (ACNM) meeting, submitted for a poster presentation at the National Nurse Practitioner Symposium in Colorado, and discussed at the Trauma-Resiliency Collaborative monthly meeting. These venues and methods of dissemination were chosen, as a poster presentation to other midwives and practitioners is vital to spread awareness on the importance of screening appropriately for IPV and implementing ACE assessment, in order to facilitate a discussion about how to implement screening in other practices. Results In terms of results, the biggest accomplishments were achieving access to mEVAL, building the tool for Birthcare Healthcare after its acceptance among the practice, receiving positive feedback from the provider meeting about ACEs and IPV, discovering a preexisting electronic version of the HARK tool, educating providers about the already existing IPV IPV AND ACES algorithms and policies, and developing a solid list of trauma-informed counselors who are 25 willing and able to see this population for high HRSQ scores. Further, chart reviews were conducted in the first week of implementation to gain understanding of how often providers were using the HARK tool and how often patients were filling out the HRSQ. I conducted chart reviews from all new obstetrical, annual, and six-week postpartum visits from all Birthcare Healthcare clinics, and I excluded problem visits or prenatal visits as these are not deemed appropriate for IPV screening. Approximately 50% of visits involved a provider using the HARK screening tool. However, providers were not utilizing the smart phrase in the note to input cores into the visit documentation. The mEVAL team provided me with data from all clinics for HRSQ screening. Madsen clinic had the highest completion rate, with 82.22% of patients completing the HRSQ, and this involved 37 completed assessments from a total of 45 visits. All other clinics had completion rates of approximately 33.33%36.84%. Barriers encountered throughout the implementation of this project included a general lack of knowledge about ACEs among IT personnel who were developing the tool, a misunderstanding of midwives' roles in obstetric clinics, lack of electronic access to the screening tool in some clinics, language barrier among non-English speaking patients, and provider inconsistency in inputting results into EPIC templates and utilization of the HARK screen. Recommendations In order for this project to have continued utility within the chosen midwifery practice, it was important for it to be sustainable and accepted by the midwives and their patients. Despite the challenges and delays that resulted from use of mEVAL for this project, it will ultimately IPV AND ACES 26 prove beneficial for the practice as it has created permanent change by embedding the tool within the EMR so providers can continue to easily use it in the future. However, some barriers still exist for mEVAL and IPV screening. When analyzing the completion rates for the HRSQ, it is important to note that the higher completion scores came from clinics that have an iPad in the waiting room to catch patients who did not complete the tool at home. Given that mEVAL is utilized by various providers and clinic types, there are key stakeholders actively involved in getting iPads at the lower completion rate clinics by end of May. This should help improve completion rates among patients. Secondly, some medical assistants are trained to put the results in the note, but this is not consistent at all clinics. Therefore, the mEVAL team will be doing further education to clinic staff on iPad use and how to access mEVAL results. I also developed a screening frequency reminder card that will be given to all midwives to improve consistency across all clinics and providers. Another recommendation is to have the appropriate smart texts include a hard stop for the providers to implement results, and this was discussed with a midwife fellow who will be working on smart texts in the near future. This same intervention will be done for HARK screening, by adding a hard stop to new obstetrical, annual, and postpartum visit smart texts. In order to improve completion among non-English speaking patients, Dr. Wiet will have the HRSQ in Spanish by mid-summer, and this may help completion rates at the primarily Spanish-speaking clinics within Birthcare Healthcare. Dr. Wiet has open communication with the mEVAL team to update this tool in various languages as needed. Another barrier faced in the implementation phase included lack of knowledge of midwife workflow and patient population, and education was provided to the mEVAL department. Further, two of the midwives involved in this project are actively involved with the mEVAL team to address these barriers and improve the utility of mEVAL. 27 IPV AND ACES Future goals are to have this project expanded to other clinics in the University of Utah, as family practice and other obstetric clinics use mEVAL, so this tool could be shared with all clinics if providers desire its use. The Trauma-Resiliency Collaborative serves as a meeting place for primary care providers, mental health counselors, and other trauma-informed individuals, and having Dr. Wiet involved in this project will allow for more providers to take on this HRSQ tool, especially if within the University system where it already exists. There are numerous opportunities for future research that could stem from this project. Such opportunities include research on patient-reported outcome systems such as mEVAL, incidence of certain scores, how many patients follow suggested interventions, and how scores change from year to year. Further, it would be interesting to see if the rates of IPV change with the updated HARK tool. While decades of research has been conducted on childhood trauma and IPV, a gap still exists in getting patients to talk about such experiences and referring to the appropriate service providers for intervention. This project successfully started to fill in that gap in a large midwifery practice in Utah, which I believe will serve as a launching ground for others to follow suit and help Utah become a trauma-informed community. That being said, the ultimate goal one day would be to have an entire mental wellness workforce or team member in the practice specifically in place for patients to discuss these types of violence. DNP Essentials This project addresses the DNP Essentials in many ways, but it most closely relates to Essential VII. Essential VII is the clinical prevention and population health for improving the nation's health. By screening pregnant women for intimate partner violence (IPV) and adverse childhood events (ACEs), the health of women, children, and families will be improved. IPV AND ACES Literature supports the fact that ACEs and IPV experiences negatively affect many health 28 outcomes of all adults, and detecting women with a history or current state of such experiences allows midwives to improve the health status of the United States population. My project requires an analysis of scientific data related to individual, aggregate, and population health as it relates to violence against women and adverse childhood experiences. Once this analysis is performed, it is imperative to screen for women who have these experiences to allow for clinical prevention of adverse outcomes. IPV AND ACES References 29 APA. (2014). The Road to Resilience. American Psychological Association. Retrieved from http://www.apa.org/helpcenter/road-resilience.aspx ACOG. (2012). Committee opinion: Intimate partner violence. Obstetrics & Gynecology, 119(2), 412-417. doi: 10.1097/AOG.0b013e318249ff74 ACOG. (2015). Adult manifestations of childhood sexual abuse. Committee Opinion No. 498. Obstetrics & Gynecology, 118, 392-395. ISSN 1074-861X Alhusen, J., Ray, E., Sharps, P., & Bullock, L. (2015). Intimate partner violence during pregnancy: Maternal and neonatal outcomes. Journal of Women's Health, 24(1), 100106. doi: 10.1089/jwh.2014.4872 Anderson, B., Marshak, H., & Hebbeler, D. (2002). Identifying intimate partner violence at entry to prenatal care: Clustering routine clinical information. Journal of Midwifery & Women's Health, 47(5), 353-359. PMID:12361347 Burke, N. (2014). Nadine Burke Harris: How childhood trauma affects health across a lifetime [Video File]. Retrieved from https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_ across_a_lifetime?language=en Eustace, J., Baird, K., Salto, A., & Creedy, D. (2016). Midwives' experiences of routine enquiry for intimate partner violence in pregnancy. Women and Birth: Journal of the Australian College of Midwives, 1-8. doi:10.1016/j.wombi.2016.04.010 Friedrichs, M. (2015). Utah health status update: Effects of adverse childhood experiences. Utah Department of Health. Retrieved from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKE IPV AND ACES wiO__- 30 W_q3NAhVT42MKHSzRBKQQFggeMAA&url=http%3A%2F%2Fhealth.utah.gov%2F opha%2Fpublications%2Fhsu%2F1507_ACE.pdf&usg=AFQjCNEmCUZkhWUQ9y0m7 dBy_x9kc3gvcw&sig2=mZs5nc_w1KTbr9t59XVPWg Glowa, P., Olson, A., & Johnson, D. (2016). Screening for adverse childhood experiences in a family medicine setting: A feasibility study. Journal of American Board of Family Medicine, 29(3), 303-307. doi: 10.3122/jabfm.2016.03.150310 Kottenstette, J. & Stulberg, D. (2013). Time to routinely screen for intimate partner violence? The Journal of Family Practice, 62(2), 90-92. PMC3601813 Luthar, S. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71(3), 543-562. PMCID: PMC1885202 LoGiudice, J., & Beck., Cheryl. (2016). The lived experience of childbearing from survivors of sexual abuse: "It was the best of times, it was the worst of times". Journal of Midwifery & Women's Health, 00(0), 1-8. doi: 10.1111/jmwh.12421 Moyer, A. (2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventative Services Task Force recommendation statement. Annals of Internal Medicine, 158(6), 478-486. doi:10.7326/0003-4819-158-6-201303190-00588 Redding, C. (2016). The adverse childhood experiences study: A springboard to hope. ACE Study. Retrieved from http://www.acestudy.org/the-ace-score.html Smith, B., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The Brief Resilience Scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(1), 194-200. doi: 10.1080/107005500802222972 IPV AND ACES Stevens, K. (2012). Star Model of EBP: Knowledge Transformation. Academic Center for 31 Evidence-based Practice. The University of Texas Health Science Center at San Antonio. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp USPSTF. (2012). Grade Definitions. U.S. Preventative Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions WHO. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. World Health Organization. Retrieved from http://www.who.int.ezproxy.lib.utah.edu/reproductivehealth/publications/violence/97892 41548595/en/ IPV AND ACES Appendix A Health-Resiliency-Stress-Questionnaire (HRSQ) 32 IPV AND ACES 33 IPV AND ACES Appendix B HARK tool for Interpersonal Violence screening in EPIC 34 IPV AND ACES Appendix C Defense PowerPoint 35 IPV AND ACES 36 IPV AND ACES 37 IPV AND ACES Appendix D Birthcare Healthcare Provider Meeting Presentation 38 IPV AND ACES 39 IPV AND ACES 40 IPV AND ACES 41 IPV AND ACES Appendix E Trauma-Informed Provider List 42 IPV AND ACES 43 IPV AND ACES 44 IPV AND ACES Appendix F HRSQ Scoring 45 IPV AND ACES Appendix G HRSQ Suggested Responses + Helpful Links 46 IPV AND ACES 47 IPV AND ACES Appendix H IPV University of Utah Policy Algorithm 48 IPV AND ACES Appendix I IPV Resource Page for EPIC Life Threatening Emergency......911 EMERGENCIES (24 HOUR) Adult Protective Services...800-371-7897 Child Protective Services...855-323-3237 Crisis/Suicide Prevention...801-587-3000 Domestic Violence Hotline.[phone] National Suicide Prevention ...................800-273-8255 Poison Control.....................800-222-1222 Rape Recovery Crisis..........801-467-7273 Sexual Assault Hotline........[phone] Trafficking National Hotline ...................888-373-7888 ADULT AND CHILD ABUSE/NEGLECT Adult Protective Services.......800-371-7897 Child Protective Services.......855-323-3237 Children's Justice Center.......385-468-4560 Guardian Ad Litem.................801-578-3962 DOMESTIC VIOLENCE Domestic Violence Hotline.....[phone] Family Justice Center............801-236-3370 Legal Aid Society of Salt Lake ...................801-328-8849 Utah Office of Crime Victims..801-238-2360 YWCA Shelter........................801-537-8600 EDUCATION Horizonte Instruction and Training ...................801-578-8574 Salt Lake Community College ...................801-957-4111 English Skills Learning Center ...................801-328-5608 EMPLOYMENT/JOB TRAINING Department of Workforce Services ...................801-526-0950 Deseret Industries..................801-240-7202 LDS Employment Services....801-240-7240 Labor Commission.................801-530-6800 People Helping People..........801-583-5300 FAMILY SUPPORT SERVICES Family Support Center (Crisis Nursery) ...................801-255-6881 Division of Child & Family Services ...................855-323-3237 Parenting Classes..................................211 Support Groups......................................211 FINANCIAL COUNSELING AAA Fair Credit Foundation...800-351-4195 Cornerstone Financial Education ...................800-336-1245 NeighborhoodWorks Salt Lake ...................801-539-1590 FOOD ASSISTANCE Food Pantries.........................................211 Food Stamps.........................801-526-0950 Home Delivered Meals Seniors ....................385-468-3200 Utah Food Bank.....................801-887-1275 WIC (Women, Infants & Children) ....................801-538-6960 49 HOUSING ASSISTANCE Family Promise Shelter..........801-961-8622 Housing Authority...................801-487-2161 The Road Home.....................801-359-4142 Youth Services.......................385-468-4500 IMMIGRATION SERVICES Catholic Community Services ....................801-977-9119 Refugee and Immigration Center ....................801-467-6060 MENTAL HEALTH Salt Lake Co Crisis................801-587-3000 UNI.........................................801-583-2500 Valley Mental Health..............801-270-6550 PEOPLE WITH DISABILITIES 711 Relay Utah.......................................711 Division of Services for People with Disabilities..............................877-568-0084 Sego Lily Center for the Abused Deaf ...............................................888-328-5486 Utah Parent Center/Autism Information .....................801-272-1051 Work Activity Center..............801-977-9779 RAPE/SEXUAL ASSAULT Rape Recovery Center..........801-467-7273 Rape/Sexual Assault Crisis Hotline ......................888-421-1100 Sego Lily Center for the Abused Deaf ......................888-328-5486 UCASA...................................801-746-0404 SENIOR CITIZENS AARP.....................................866-448-3616 Salt Lake County Aging Services .....................385-468-3200 SEXUALLY TRANSIMITTED DISEASES/AIDS Planned Parenthood Association .....................801-532-1586 Utah AIDS Foundation...........801-487-2323 SUBSTANCE ABUSE Alcoholics Anonymous...........801-484-7871 Al-Anon Family Groups..........801-262-9587 Narcotics Anonymous............877-479-6262 SL County Assessment and Referral Unit .....................801-468-2009 Tobacco Quit Line..888-567-TRUTH (8788) UTILITIES American Red Cross.............801-323-7000 Assist, Inc (Emergency Home Repairs) .....................801-355-7085 HEAT (Home Energy Assistance Target) .....................801-521-6107 Questar Gas (Customer Service) .....................800-323-5517 Utah Telephone Assistance Program .....................800-948-7540 Rocky Mountain Power..........888-221-7070 HELP WITH PRESCRIPTIONS If you need a prescription but do not have health insurance, RxConnectUtah might be able to help: http://www.health.utah.gov/rxconnectutah/ For discounted drug prices go to: goodrx.com **Typing ".RESOURCE" will drop this into EPIC AVS or visit note IPV AND ACES Appendix J Screening Frequency Reminder Cards 50 IPV AND ACES Appendix K Defense Poster 51