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Working Together for a Healthy New York 1998
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Injury Prevention
Injury Prevention Network, New York City
Public Health Priorities Partnership, Injury Prevention for Youth, Upper Hudson Primary Care Consortium
Safe Passage Program, Sisters Hospital, Buffalo
Safety Works, Think First of CNY, Inc., Syracuse
Suffolk County Disaster Response
The Partnership to Prevent Domestic Violence, New York and the Bronx The Rochester Council on Occupational Safety and Health
The Village of Candor 1997 Partners in Rural Traffic Safety
Think Sharp! Madison County Safe Syringe Disposal Program
Ulster County Healthy Start Program
Ulster County SANE (Sexual Assault Nurse Examiner) Program
US Healthcare and Victim Services, Current Concepts in Womenís Health: Domestic Violence and Primary Care, New York-Based
NEW YORK CITY |
Mission/Purpose
The Injury Prevention Network was born in 1997. The Department of Health and Human Services Maternal and Child Health Bureau Injury Prevention Liaison in Region II felt that there was a need to both identify and integrate the efforts of various agencies involved in injury prevention.
Leadership
The Injury Prevention Regional Liaison contacted state and local agencies interested in working together to create safer environments and a better future for city youth. Several of these agencies accepted an invitation to meet at the Federal Office Building to get to know one another. After the first meeting, the group decided to meet again to identify those areas requiring immediate action and to brainstorm what could be done. After analyzing the city and state data/statistics for causes of death and injuries, it was agreed that adolescents were at high risk. The group decided to organize a conference to address the needs and problems confronting the cityís youth.
Key Partners/Stakeholders
The New York Task Force for Immigrant Health, The Door: A Center of Alternatives, and The Mount Sinai Adolescent Health Center were also invited to meet with federal and state agencies and to participate in the network. The Planning Committee was formed and the conference planning got underway. The Hunter College Center for the Study of Family Policy joined the network and provided a site for its first conference, scheduled for June 3, 1998. The members of the Planning Committee committed themselves to the task of finding and inviting knowledgeable speakers to present at the conference. Dr. Donald F. Schwartz of the Childrenís Hospital and the University of Pennsylvania in Philadelphia agreed to be the keynote speaker. Many other highly qualified and motivated individuals also offered their support and expertise.
Impact/Effectiveness
This conference was also designed as a first step toward establishing communication among the many agenciesóstate, local, and communityóworking on the same goals. The conference was held and was well attended.
The Planning Committee consisted of state and local Departments of Health, community and hospital adolescent centers, and other community agencies dedicated to the well-being of adolescents. All of these members deserve a lot of credit for the success of the conference. Evaluations of the conference revealed that those in attendance thought it was a success but that more time was needed to network and to find out about funding sources. Efforts are currently underway to satisfy these concerns through mini conferences. An additional conference has been scheduled to address the need for further information about grants and funding sources.
Funding
The Injury Prevention Network was able to obtain funds for this conference and for a few follow-up activities from the Department of Health and Human Services U.S. Public Health Service: Office of Minority Health, Office of Womenís Health, and Office of Family Planning; the Health Resources and Service Administration Maternal and Child Health Bureau; and the New York State Department of Health.
Contact: Maria J. Diaz, M.P.H., C.H.E.S., Public Health Advisor, Injury Prevention Liaison, Department of Health and Human Services, Region II, Jacob K. Javits Federal Building, 26 Federal Plaza, New York, NY 10278. Telephone: (212) 264-5494. Fax: (212) 264-1324.
INJURY PREVENTION FOR YOUTH UPPER HUDSON PRIMARY CARE CONSORTIUM |
Over the past two years, the Upper Hudson Primary Care Consortium (UHPCC) has been working with two local health units (LHUís), Warren County Public Health Services and Washington County Public Health Services, on an initiative to identify regional health issues prevalent among the 0ñ21 age group and amenable to improvement through intervention.
The project commenced under the leadership of the LHU in each county. Secondary data, previously collected by UHPCC for the purpose of preparing community health assessments for the individual counties, was aggregated and special attention given to causes of morbidity and mortality among those ages 0ñ21 in the bi-county area. It was noted that one of the most prevalent reasons for the need of health care services by this population was preventable injury. Further examination of the data revealed that within the younger portion of that age group, roughly those 0ñ6 years old, both physical and sexual abuse (often occurring in confirmed settings of domestic violence) and neglect were the principal types of injury noted. Primary school and younger middle school children demonstrated a tendency to suffer accidental injury. Health problems in the older age group were largely self-inflicted through means that included tobacco use, drug and alcohol abuse, sexually transmitted diseases, adolescent pregnancy, and suicide or attempted suicide. Thus, for the entire age range, injury was deemed the common denominator.
In order to corroborate the accuracy of secondary data, especially with respect to self-inflicted injuries, a survey of personal habits and lifestyles was developed for completion by students in health education classes at 21 public schools throughout the bi-county area. Teachers at each school agreed to participate, and more than 340 anonymous student surveys were subsequently returned. The aggregated input from those primary data sources was remarkably consistent with both the secondary data and nationally reported findings.
At this point, because of the need for comprehensive input from those agencies that provide direct, mostly non-health-related services to youth, it was determined that the development phase of the project necessitated the involvement of each countyís Youth Bureaus, which routinely interact with these youth service providers. Community Planning Groups (CPGís) were formed with representatives from a variety of community agencies, businesses, schools, and parent groups. The CPGís were given the principal tasks of identifying factors that contribute to the injury phenomenon and suggesting actions that might lead to their resolution. The outcome of these meetings was consistentóparenting skills, readily accessible and routinely applied, were the key element in injury prevention. The CPG group proceeded to draft a strategic plan that addressed three goals related to resources that should be available to parents to assist them with preventing injury to their children: Education should be both comprehensive and coordinated; there should be easy access to these educational resources; and there should be universal awareness of these parenting services.
In order to meet these objectives, the CPG adopted a work plan calling for the convening of public forums for parents in a minimum of two communities in each of the two counties. The purpose of these forums was to engage parents in the identification of comprehensive strategies for injury prevention and to secure their commitment to collaboratively pursue those strategies. In the process of planning the forums, it became clear that a number of groups, among them schools and constituent organizations of the Youth Bureaus themselves, were already promulgating efforts to educate and engage parents in programs of injury prevention. However, it appeared that many of these efforts were broadly focused and, to some degree, lacked continuity. As a result, the CPG determined to pursue a marketing campaign that would reach out to parents with a consistent message in as many of their environments as possible. The campaign was to be based on seasonal, age-specific behavior that could place children at risk of injury.
The strategies selected involved the distribution of injury prevention information to parents at key access points in the community. The goal was to assure that parents would literally be inundated with information at schools, health care providers, youth organizations, community centers, social service agencies, and so on. In order to make the information topical, brochures were prepared for each season of the year and included key preventive tips for each age group. These brochures also included listings of community agencies and area resources available to parents and children in the bi-county region. The effort to evaluate this approach is ongoing. Feedback has been continually gathered from brochure distribution sites and directly from parents/consumers.
The final aspect of the injury prevention campaign calls for establishing a pilot parenting program to encourage and equip parents in conflict resolution/communication skills with a special emphasis on dealing with situations that have the potential to lead to violence at school. Additionally, a special emphasis has been placed on equipping parents with skills to prevent the escalation of conflict as a result of the use of firearms. This component of the campaign will be implemented in the school settings in the last quarter of 1998.
Contact: Lynne Hamilton-Silverberg, R.N., Assistant for Special Projects/Grants Administrator, Upper Hudson Primary Care Consortium, One Broad Street Plaza, P.O. Box 3253, Glens Falls, NY 12801. Telephone: (518)-761-0300. Fax: (518)-745-1378. E-mail: silverly@uhpcc.medserv.net
SISTERS HOSPITAL BUFFALO |
Mission/Purpose
The Safe Passage Program at Sisters Hospital is the first comprehensive hospital-based family violence program in western New York. Recent reassessment of the health care needs of women has revealed that domestic violence significantly affects womenís physical and emotional health; yet, historically, this problem has not been identified or treated as a health care issue.
Research indicates that, other than from law enforcement, women will most likely seek help from their health care provider or facility. In addition, 22-35 percent of women receiving assistance in the emergency department exhibit symptoms of domestic violence and fewer then 5 percent are identified. Once the magnitude of this problem was identified, the Safe Passage Program was established in order to be more responsive to the health care needs of women. The success of the program indicates more than anything else the great need among women for such a service. Since the programís inception in 1994, its services have expanded to include elder abuse, which affects over 2 million older people annually yet is highly underdetected.
The purpose of the Safe Passage Program is to help end family violence in order to improve the quality of life of those affected and to help define, for the hospital and the community, family violence as a health care issue. In order to meet the goals of the program, several priority areas were established including 24-hour advocacy, medical care provided by health care providers trained in family violence intervention, 24-hour spiritual support, outpatient mental health, employee assistance, and educational programs for health care providers and the community. In addition, the hospital renovated a two-family house in the community into a fully furnished transitional living home for victims of family violence. Women and their children are permitted to remain at the facility for up to 18 months. The home is owned and operated by Sisters Hospital and is the first and only transitional living home in Erie County.
When the director, Kathleen Slammon, C.S.W., was hired in 1994 to coordinate the programís development and implementation, it was obvious to her that family violence could not be effectively confronted by a single individual or institution. In order to have a successful hospital-based program, she would have to build strong partnerships with providers in her own hospitalócommunity service providers. Also, it was important to ensure that the programís goals were incorporated and supported by the mission of the hospital. This strategy strengthened the program and empowered her as its leader to invite other providers to feel comfortable in joining the collaboration.
Initially, an internal hospital task force of administrators and health care providers was created to establish a team approach to programming. The director also joined the Erie County Coalition Against Family Violence, a 20-year grassroots coalition, and cochaired the Coalitionís training committee. As cochair, the program director has been responsible for recruiting membership and planning an annual training program on issues of family violence, which is offered to the general public. The 1998 program attracted over 200 people to the three-part series.
In order to implement three main components of the programóadvocacy, mental health services, and case management servicesópartnerships were established with three community agencies: Crisis Services, Monsignor Carr Institute, and Haven House. The director led a pilot project between Crisis Services and Sisters Hospitalís emergency department. The project involved expanding the Crisis Services volunteer advocate program for sexual assault victims to include domestic violence victims. The director trained the volunteers in domestic violence intervention and, together with the coordinator of the advocate program, developed a 24-hour response system.
To assist with facilitation of tenant selection and case management services for the Safe Passage House, a partnership was formed with Haven House, the local battered womenís shelter. Haven House agreed to screen and select the potential Safe Passage House tenants from their acute shelter. To avoid duplication of services, Haven House would follow these tenants from Haven House through their stay at the Safe Passage House and monitor their needs and progress.
To aid in the provision of comprehensive mental health services not offered at Sisters Hospital, a partnership was developed with Monsignor Carr Institute, a community mental health center. As a licensed clinical social worker, the director joined the staff at Monsignor Carr seven hours per week, specializing in counseling victims of family violence. Referrals include patients and employees from the hospital and the general community.
Each of the partnerships described above enhances service delivery to victims of family violence without duplication of staff or services. This approach allows for comprehensive and consistent care that is efficient and effective. The directorís vision of a healthy community includes individual and community empowerment and easy access to care. Empowerment is achieved through education and information, which have been established as the foundation of the Safe Passage Programís intervention model. The director has also conducted numerous educational programs for various organizations in the community. In addition, the partnerships described above enable the development of healthy communities by increasing the availability and accessibility to a variety of services.
Leadership Role
Sisters Hospitalís board of directors governs the Safe Passage Program, but daily leadership is the responsibility of the program director. The director reports to the director of Womenís Health and has ongoing collaboration with partnering agencies and departments. A team approach to program planning and implementation has been a primary component of the directorís leadership orientation. Leadership has focused on enabling working groups or partnerships to utilize their strengths in a manner that is beneficial to the whole (i.e., filling gaps in services) . Individuals in the groups must feel that they are an integral part of the process in order for them to remain interested and active partners. This is achieved by actively listening to their ideas and proposals and implementing them into the planning process when applicable.
In leading the effort to define family violence as a health care issue, the director cofacilitates a countywide working group named Healthcare Emergency Response Violence Intervention Project (HERVIP). This group was formed in 1995 following a summit sponsored by former Legislator Len Lenihan that highlighted health care and domestic violence. Significant interest resulted from this summit; therefore, Sisterís Hospital offered to cosponsor a meeting led by Sisters, Legislator Lenihan, and Haven House. As the host, the SPP (Safe Passage Program) director coordinated the planning of the event, in collaboration with Haven House and Len Lenihan, which included a luncheon meeting with CEOs and senior management from each hospital in Erie County. The purpose of the meeting was to address the issue of domestic violence and health care and to find ways to work together as a community to provide consistent care to victims throughout the countyís health care system. Using the Safe Passage Program as a model, participants were able to see the possibilities and positive outcomes of health care intervention. A working group (HERVIP) of representatives from each of the 11 hospitals was formed as a result of this meeting. The group identified the following three goals: the creation of a standardized countywide protocol, education, and funding. To date, HERVIP has successfully developed a protocol to be adapted and used by each hospital; funding was received for research; and HERVIP members are currently working on an educational program that will assist in instituting the protocols.
Key Partners/Stakeholders
The principal partners include Haven House (battered womenís shelter), Crisis Services (rape crisis center), Monsignor Carr Institute (community mental health center), and most recently, Catholic Charities. Haven House staff members provide case management services to the two families who reside in the Safe Passage House. They are also responsible for the screening and selection of the Safe Passage House tenants.
Crisis Services provides 24-hour advocacy to Sisters Hospitalís emergency department and responds on the shifts not covered by Sistersí social work department. Advocates are trained in domestic violence and sexual assault intervention and assist with safety planning and offer support to the victim. All victims receive follow-up, which is provided through either Crisis Servicesí staff or the Safe Passage Program. As mentioned above, Sisters Hospital and Crisis Services piloted the domestic violence advocacy project at Sisters, and because of its success, the program has expanded to other hospitals in the area.
Through the partnership with Monsignor Carr, comprehensive mental health services are available to victims of family violence. Partnering allowed the Safe Passage Program to enhance services, while providing Monsignor Carr with a clinician specializing in family violence.
In order to expand the scope of the Safe Passage Program to include elder abuse, the director organized a task force of hospital and community providers. As a result, a protocol outlining the process of care for elder abuse patients was developed and partnership with Catholic Charities was formed. The partnership was established as a means to close the gap between the provision of hospital-based and community-based services for the elder abuse client. In addition to training the emergency department staff on elder abuse identification and intervention, Catholic Charities will followup on all hospital social work referrals of elder abuse patients discharged to the community. Follow-up will include intensive case management and referral services by the Catholic Charities staff, who will then communicate intervention outcome back to the referring social worker and the patientís primary care doctor.
The selection of community partnerships was based on victimís needs and service gaps, with careful consideration of issues of race, culture, language, socioeconomic status, sexual orientation, religion, and ethnicity. Additional partners will be included as the program changes and evolves. Continual monitoring and evaluation of the program ensures this potential inclusion.
A team approach to decision making is promoted, and subcommittees and planning meetings are organized to discuss and review programming and services. The responsibilities of each partner are to fulfill the roles stated above and to do so with respect to our collaborative process. This would not be a successful approach without the support of each partnerís administering body and commitment to work collaboratively.
Significant effort has been made to promote participation from the community. Sisters Hospital worked together with the Parkside Community Association and the City of Buffalo in the development of the Safe Passage House, which is located in the Parkside community in Buffalo.
Also, last year, in recognition of National Domestic Violence Awareness Month and as a means to promote the availability of family violence services at Sisters Hospital, the Division of Womenís Health at Sisters Hospital sponsored the Safe Passage Programís first annual walk, Heal the Hurt. The walk attracted over 100 walkers from the community, including concerned individuals and service providers. The walk was coordinated in collaboration with the YWCAís national campaign, Week Without Violence. In an effort to gain participation from the three neighborhoods surrounding the hospital, presidents of the three neighborhood associations were invited to be honorary cochairs of the walk. Following the walk there was a reception to promote networking and socializing among the three distinct communities around the common issue of violence. The cochairs and neighbors were recognized and the Safe Passage Programís services were promoted. The 1998 Heal the Hurt walk planning committee will expand to include the recently merged Catholic Health System, which incorporates six hospitals. The purpose of the 1998 walk will include raising awareness of family violence and the services provided by the Catholic Health System, in addition to bringing the diverse Catholic Health System together on a common issue.
Impact/Effectiveness
Historically, family violence has not been considered a health care issue, yet health care facilities and providers are often the first places women go to for help. This fact places health care providers in a unique position to intervene in the familyís chronic cycle of violence. Changing health care providersí perceptions about family violence is the key to providing the most effective care for victims. Not until providers are informed and believe that it is their responsibility to ask about violence, document reports of violence, and discuss safety plans, will their care of victims be comprehensive. Since this approach is a change from how family violence has been treated historically, changing the culture of the health care environment in the way it perceives and treats family violence will be the ultimate measure of effectiveness of the Safe Passage Program.
As a means to this end, in the first year of the program the director developed a curriculum that taught health care providers about the cycle of violence, how to identify and intervene with victims of family violence, and the hospitalís protocol of care. With endorsement from administration, this education program on Family Violence Identification and Intervention was instituted. All providers who have patient care responsibilities are mandated to attend this program once a year. To assist in expanding this educational program, the director developed a train-the-trainer curriculum in 1997 and recruited six hospital employees who agreed to volunteer to complete the train-the-trainer program and teach the family violence classes.
As a result, in 1997 over 1,000 employees completed the one-hour program. Since the inception of the Safe Passage Program, approximately 3,000 employees have participated. Over 300 patients were identified and treated for family violence in 1997 and about 750 since 1995. The Safe Passage House has provided a safe home to six families since it opened in 1995, and for the first time in its year of operation there is a waiting list for mental health services. These statistics indicate an increase in numbers identified each year, which means that more people are receiving services and providers are becoming more sensitized to the issue. These numbers also reflect the results of extensive efforts to expose the program to as many entities as possible through the directorís involvement in public speaking, working groups, committees, and conferences. In addition to tracking numbers, quality review of emergency department cases is completed and feedback from providers and patients is encouraged to ensure that victim care is consistent and comprehensive.
The design of this program was meant to be most beneficial to the client/patient. Again, an objective of the program is to increase victim identification by sensitizing the provider through education. As providers become more aware of this issue, they will feel more comfortable in approaching and treating family violence. This approach will promote patientsí accessibility to consistent, comprehensive, and sensitive care, which will ultimately improve the patientsí safety and quality of life.
Utilizing the Safe Passage Program as a port of entry for victims is beneficial to victims as well as those who are partners in the program. Collaborative programming allows for the availability of an expansive array of services that can be accessed through one program. More clients are served without the risk of ìfalling through the cracks,î and partnering programs receive referrals in a manner that promotes shared responsibility and increased communication.
Currently, the Safe Passage Program is funded by Sisters Hospital. In the past it has received support from the Hospitalís Foundation, the City of Buffalo, and a NYS legislative grant. The director is the only paid staff and utilizes volunteers and other programs to meet the staffing needs of the program.
As described in various projects, the community support has been striking. The Parkside Community Association played an integral role in the Safe Passage House planning process. The hospitalís three surrounding communitiesóParkside, F.L.A.R.E., and Trinidadósupported and participated in the Heal the Hurt walk, along with others throughout the area. It will be important for the growth and the success of the program to continue to involve the community in the programís planning and special projects.
Possibly triggered by competition for resources, collaborative programming has the potential to fail because institutions appear hesitant to share resources and ideas. This inhibits the ability of communities and programs to work together and ultimately affects client/patient care and communities as a whole. The Safe Passage Program and House have demonstrated successful and effective partnerships and prove that a collaborative approach does work.
Contact: Kathleen Slammon, M.S.W., C.S.W., Safe Passage Program Director, Sisters Hospital, 2157 Main Street, Buffalo, NY 14214. Telephone: (716) 862-1947. Fax: (716) 862-1436.
A brochure is available upon request.
THINK FIRST OF CNY, INC. SYRACUSE |
Mission/Purpose
The purpose of the Safety Works project is to make comprehensive injury prevention information available, accessible, and understandable for individuals with poor English comprehension skills and/or poor reading ability.
The goals of the project included:
- the development of a comprehensive manual of safety topics to be included in one system.
- the access to safety information for the target audience. This information would be written and illustrated for adults with a reading ability below the fifth-grade level.
- the accessibility of the manual to tutors. The manual would include instructional goals, background information, and reinforcement activities in each section.
- the development of Safety Works as a collaborative community project in order to include all of the main points that should be covered and to achieve the greatest accuracy.
The projected audience for Safety Works would include tutors from literacy organizations (Literacy Volunteers of America and Laubach), refugee programs, social service agencies such as Head Start that typically serve low-literacy clients and businesses that employ a number of employees who either do not understand English well or who do not read above a fifth-grade level.
The first step in the development of this project involved recognition of the problem: People who do not read, write, or speak English are at greater risk for injury. Injury prevention educational materials are almost exclusively written for a literate population; furthermore, the information (printed material) is fragmented and not readily available.
With the above in mind, this agency approached the Rosamond Gifford Charitable Corporation on an informal basis to explore their interest in the development of a tool to address the problem. The executive director, who is familiar with the community, suggested and encouraged the development of a community partnership.
The first agency to be included and a natural partner was Literacy Volunteers of Greater Syracuse. Meetings with their staff led to the development of a coalition as other partners were identified.
Those partners included representatives from Think First of CNY, Inc.; Literacy Volunteers of America; the American Red Cross; New Justice Services; Onondaga County Public Library; and the Refugee Assistance Program.
Meetings were held on a regular basis beginning in the fall of 1995. An outline of the scope of the project was developed as well as a strategy for achieving the stated purpose. Each partner had an assignment to either research a particular topic (such as water safety for the Red Cross) or to contact a professional in the field. Partners then extended the contacts by interviewing representatives from the CNY Poison Control Center, Lead Poisoning Center of CNY, City of Syracuse Fire Department, Onondaga County Health Department, Laubach Literacy Program, Contact (a local agency), and so on.
The strategies used to develop Safety Works were arrived at through discussions with individuals and agencies who are in daily contact with recent immigrants or persons with literacy problems. Several members of the coalition had immigrated years ago, and their recollections of difficulties were helpful. Initially, the coalition interviewed tutors from the Refugee Assistance Program and from Literacy Volunteers of Greater Syracuse. Tutors from the Refugee Assistance Program are paid staff and see a rapid turnover of their students, many of whom are often out in the workforce within a few weeks. They were overwhelmingly in favor of the development of an easy-to-use tool for injury prevention education. They referred to awareness of topics such as fire safety, poison prevention, and street smarts as ìsurvival skillsî for people new to this country.
Tutors from Literacy Volunteers see their students for a longer duration. They are always looking for educational materials that include lesson plans and reinforcement activities. They were excited to hear about the possibility of a tool that would help teach basic English speaking skills and at the same time convey important safety information.
On the basis of these interviews, a grant application to the Gifford Foundation was written. That it was approved reflects the cooperation of the executive director and the board of directors from the Gifford, who represent diverse backgrounds.
Once the grant was approved, RFPís were circulated to advertise the availability of contracts for a writer and an illustrator. Their assignment was to use the information gathered by the coalition partners and to write and design the manuscript.
When samples of the first draft were available for a pilot study, they were distributed to the above-named organizations for feedback. Initial corrections and suggestions were incorporated into the final design.
The standards of a healthy community are achieved by an educated and empowered citizenry. A healthy community will include:
- Excellent schools with teachers and staff that are motivated to bring out the best in their students; a physical plant conducive to learning; and the necessary resources to maintain a high standard of achievement.
- A healthcare system that is available and utilized by all citizens as they require it. Infant mortality rates will be within normal limits as a result of available and accessible pre- and post-natal care and pediatric services. The numbers of preventable diseases and unintentional injuries will be on the decrease because individuals know how and choose to play their required part in their personal well being.
- Safe neighborhoods with satisfactory homes, streets, parks, and playgrounds that are a deterrent to violence and intentional injuries.
- A healthy job market so people are able to earn an adequate living; thereby creating a sense of well being and respect for themselves and others.
Leadership Role
The leadership structure for this project was initially established by Think First of CNY, Inc. Initial inquiries concerning the problem and the possibility for an innovative project were carried out. Once affirmed, Literacy Volunteers of Greater Syracuse, Inc. (LVGS) quickly became a partner. LVGS provided the expertise in literacy aspects of the project, screening applicants for the writing and illustrations, and is a continuing presence in determining the quality of the final product. Both organizations attended meetings, interviewed potential teams, and contributed to the design. Think First scheduled and held meetings; collected the information and topic outlines; interfaced with the writer, illustrator, subsequent graphic designer, and printer; and saw to it that logistical details were managed. Think First also developed and presented the budget to the partners and has since handled the finances of the project. At completion, it is Think Firstís job to distribute the manuals throughout the community, to report to the Gifford Foundation, and to collect evaluations of the finished project.
Technical assistance was solicited with respect to how to effectively proceed with this project. The initial conversations with Dean Lesinski (executive director of the Gifford Foundation), Ruth Colvin (founder of Literacy Volunteers of America), and the successive executive directors of LVGS provided the direction that subsequently led to the success of this project. Partners asked other community resources for their input, and these conversations were recorded and reported back to the coalition.
Key Partners/Stakeholders
Key partners/stakeholders included the following:
- Think First of CNY, Inc.: Nancy Stewart, (executive director); Mike Davison (brain injury survivor), and Mary Jeschke (social worker in an inner city school). Think First board members include representatives from the Onondaga County Health Department who are interacted with on a regular basis and whose input is significant.
- Literacy Volunteers of Greater Syracuse, Inc.: Mark Cass (initial executive director), Kathy Scholl (current executive director), Wendy Edwards, Joanne Delaney, Joan Newland (all staff), in addition to their tutors.
- Refugee Assistance Program: Bob Huss, (executive director), in addition to their tutors.
- American Red Cross: Bob Bewley (water safety resource person).
- New Justice Services: John McCollough, executive director (weapon safety advisor).
- Onondaga County Public Library: Melina Hansen, a librarian who immigrated to this country years ago.
- An unofficial partner but ongoing and valued advisor is Ruth Colvin, founder of Literacy Volunteers of America.
The process of this project depended on developing a representative partnership of agencies within the community who are involved with safety issues. Initial discussions with LVGS and a knowledge of safety topics provided an outline of the areas of concern. Once those were identified, the coalition members contacted the agencies that address such needs. Think First is involved in brain and spinal cord injury prevention and therefore had information and resources pertaining to motor vehicle, pedestrian, and bicycle safety. The Syracuse Chapter of the American Red Cross helped with water safety as well as first aid and emergency measures. New Justice Services helped with weapon safetyóan area of political dissension that had to be handled tactfully but effectively. The partners identified areas to be covered and then spoke extensively to educational staff from the local fire department, poison, and lead poisoning centers. They also spoke with intensive care nurses about the current atypical type injuries they were seeing (like children falling out of second-story windows). Their up-to-date concerns are covered.
The partners were selected because of their expertise and their connection with the targeted community. Through their contacts, the development of Safety Works was expanded. Several members of the coalition attended meetings with tutors from the Refugee Assistance Program and LVGS in order to discern their interests and needs. Other members helped with revisions and editing of the copy. It was a process that necessitated the input from a variety of viewpoints.
There were separate phases for the first edition of the manual:
- Once the partners were identified, consensus was reached regarding the scope of the project and the way in which technical aspects would be contracted for.
- Material was gathered by individual partners and was written up before discussion and approval in committee.
- These materials were turned over to the writer, who designed the format, did the writing, collaborated with the illustrator, and then reviewed his results with the contact person.
- The partners then reviewed the results, made corrections and suggestions, and sent the revisions back. This review involved prioritization in addition to content suggestions.
The initial edition of the manual, Safety Works, is now in the evaluation phase. Copies are being circulated to encourage use and evaluation. The next phase will involve making the necessary revisions and then publishing the work for wider use. The evaluations will determine future stakeholders. Literacy Volunteers of America, Inc. and Think First of CNY, Inc. will be involved in making revisions. Local experts will be contacted for any area that needs to be strengthened.
Impact/Effectiveness
Success will be measured by: (1) the extent of the use of Safety Works; (2) the degree to which it facilitates injury prevention education, and (3) feedback on how the target audience views its effectiveness. The highest measure of success will come from knowing that injury has been avoided because information shared has kept someone from getting hurt, but at this point the only tool for measuring that is anecdotal evidence.
A needs study was conducted before the project got underway. It confirmed the fact that there was no comprehensive injury prevention tool to address those who possess low-literacy or poor English comprehension skills. Included in the manual are evaluation forms requesting feedback from its users once theyíve employed it for a period of time (six weeks to two months). Details about how tutors regard this effort will be gathered; necessary revisions will follow.
An initial measure of success is the demand for the manual, Safety Works. One example: After circulation to the initial target audience, requests have been received throughout the state from Head Start representatives. They say that it provides them with a complete resource and that as they make site visits, they can survey the home situation. Depending on what they find, they can decide which portions of the manual to use.
There is satisfaction in knowing that the initial layout is working. The tabulated sections make the location of a topic easy. The content of each section can stand alone; it is not necessary to have completed one unit before moving on to another.
Safety Works has been funded by a grant from the Gifford Foundation. It has been carefully budgeted to cover costs of development, printing, circulation, and administration, and this budget is realistic and on target.
The targeted audience was identified by definition of the project, and there was keen interest from the organizations that serve that population. With contacts and inquiry, other logical uses have been realized. Head Start is a major supporter. The SUNY Health Science Center Library has a community resource service, and they were happy to have a copy. The Onondaga County Public Library works with literacy training so they were receptive. BOCES will be able to use Safety Works as well.
There have been suggestions to translate Safety Works into Spanish and other languages. Support has been strong enough to indicate that this edition is just a beginning.
The first significant milestone was getting the document completed! It was more work than anyone envisioned to finish this project so that it met standards and expectations.
Another milestone was achieved with the receipt of an Allstate grantóbased on initial draftsóto take this project to another level with a wider circulation through Literacy Volunteers of America. This was not anticipated at the outset.
Further significance: Safety Works was on display at the Think First Foundation National Conference late in April, and the interest from directors was notable. The coordinator from Alabama could anticipate wide use in that area of the country. A person from Vermont who worked with a huge immigrant population was very supportive. And a director from Montreal thought that it would be wonderful to have such a resource available in French.
Although there are natural territorial issues for all organizations, there were no significant problems in the development of Safety Works. If there has been a problem, it is a lack of recognition of the importance of prevention and of this ìsubspecialtyî of low-literacy information. However, reputable medical journals have published articles on the importance of attention to literacy abilities in many aspects of health care (for example, patient information and medication instruction), so there is an expectation that acceptance of this need will be more widely acknowledged.
Contact: Pam Porter, Board President, Think First of CNY, Inc., Rehabilitation Center, University Hospital, 750 East Adams Street, Syracuse, NY 13210. Telephone: (315) 464-2330. Fax: (315) 464-2305.
E-mail: Pporter@syr.iroquois.org
Kathy Scholl, Executive Director, Literacy Volunteers of Greater Syracuse, Corner of East Colvin and South Salina Streets, Syracuse, N. Y. 13205. Telephone: (315) 471-1300.
A copy of Safety Works (manual) is available for interested individuals on request. A charge of $15 will also cover shipping and handling costs. Please send requests to Think First of CNY, Inc., 750 East Adams Street, Syracuse, NY 13210, or call (315) 464-2330.
On the night of July 17, 1996, at approximately 8:35 p.m., TWA Flight 800, bound for Paris, France, crashed into the ocean approximately ten miles off the coast of Suffolk County after taking off from JFK Airport in New York City. As the chief elected official in Suffolk County, County Executive Robert J. Gaffney immediately took charge of the situation.
The first action to be taken was to secure an area at a site in close proximity to where the aircraft had crashed. It was obvious from the start that this was a major incident, and securing the area would prevent onlookers from interfering with the work of professionals trained in handling disasters. County Executive Gaffney decided to utilize the Coast Guard Station in East Moriches as the primary staging area. Suffolk County Police Department officials immediately established a perimeter extending one mile from the Coast Guard Station. Within the next half hour that perimeter was extended to approximately three miles from the site.
The county executive made sure that access to the site was severely restricted to emergency personnel, law enforcement officials, and government officials. Immediately following the crashóand over the next several weeksómore than 1,200 police officers were involved in the operation. Their duties were many. They established an investigative command post to brief various emergency personnel. They maintained traffic control and coordinated the movement of debris removed from the water. The departmentís Marine Bureau worked on body and evidence recovery, and they assisted FBI personnel in fingerprinting and photographing the victims.
Police department officials werenít the only ones at the scene. The countyís Department of Fire, Rescue, and Emergency Services came to the scene within minutes of the crash. Additionally, the county maintains an Emergency Operations Center, which the county executive ordered immediately and fully staffed. The Center established clear radio contact with all fire departments and emergency medical units in the county, as well as all law enforcement agencies. All of these links were opened, and the EOC began operating in a 24-hour mode.
The county executive activated the countyís Incident Management System (IMS). The IMS coordinated the efforts of more than 60 agencies, determining which jobs would be performed by whom and which agencies would handle various responsibilities.
The Coast Guard and Suffolk Police Marine Units arrived at the crash scene minutes after being notified. In less than half an hour after the crash, experts from the County Medical Examinerís Office arrived. They, along with Coast Guard and police personnel, immediately set up a temporary morgue. Refrigerated transport trucks were called in to help transport bodies back to the Medical Examiners Office.
Sanitarians from the countyís health department were also called to the scene, as were other health department officials including the departmentís Emergency Medical Services Division. The health department notified Brookhaven Memorial Hospital and Stony Brook University Hospital to immediately implement their External Disaster Plan. The hospitals, under that plan, are equipped to handle the immediate influx of up to 150 emergency cases. They remained on alert under this plan until approximately 11 p.m. that evening, when it became obvious that there would not be any survivors of the crash.
The county health departmentís Mental Health Unit was also on hand. It was their charge to activate the unitís Critical Incident Stress Debriefing. However, these individuals were not needed at the crash site that evening. Their first duty would be to meet with the families of the victims of the crash. Later on, they would work with the Police Department; Fire, Rescue, and Emergency Services; other health department officials, and civilians in the community who were affected by the crash.
Within minutes of the incident, members of the media descended on the scene. After being briefed by the various officials at the site, the county executive briefed the media on the events of the evening.
Officials from the countyís sheriffís department were also on the scene. They arranged for all 21 police agencies in the county to communicate together on one frequency and relieved police personnel from time to time. Additionally, they used department vans to transport emergency personnel to different areas of the command site.
The county executive also made sure that the countyís Department of Public Works was on the scene. One of their first jobs was to establish an explosives disposal area in case any explosive devices were picked up. Also, knowing that officials would be coming to the site from around the state, they constructed a helicopter landing pad.
The county executive also mobilized the Suffolk County Park Police. Their duty was to secure the beaches around the crash site. They inspected the beaches for any debris that might have washed up and, at the same time, kept the general public away. They considered the beaches a potential crime scene and treated it as such.
The County Medical Examinerís Office worked around the clock. During the days immediately following the disaster, some 400 peopleófour times the normal numberóworked to identify bodies.
In addition, medical personnel from around the state responded to the sceneóprimarily dentists. Because of the condition of the bodies being retrieved from the water, dental records were used for identification. X-ray technicians also assisted in the identification process.
The county has four mental health counselors. It is their job to help people who have been traumatized by a particular incident. Because of the magnitude of this disaster, an additional 61 counselors offered their services. The County Medical Examiner likened the impact suffered by those onboard Flight 800 to that of a person traveling at 400 miles per hour and slamming into an immovable object. Most of the personnel conducting the recovery operation had never experienced the results of such a disaster, and the work of the mental health counselors proved invaluable. Even so, many of the personnel at the site were severely traumatized by what they witnessed and did not return to work for an extended period of time. To this day several people who were at the site are still undergoing counseling.
Divers worked in shifts, recovering bodies and personal belongings. There are numerous risks with diving at 100 feet in cold water. Therefore, a nutritionist and other medical professionals were available to address the needs of divers.
A top priority for all at the site was identification of the bodies recovered. Some of the victims had identification on them. Others could be identified through fingerprints or dental records. Still, some of the bodies were so damaged by the crash, and subsequent immersion in over 100 feet of water, that traditional means of identification were useless.
In many cases, the office utilized DNA profiles. This was the first time in history that DNA technology was used extensively in a mass catastrophe. Specialists went to the homes of those persons who were on Flight 800 and collected personal items. DNA was extracted from these items and compared to the DNA of the victims. Positive matches confirmed the identity of the remaining victims. Using this and other technologies, all victims of Flight 800 were identified.
Less than two hours after the downing of the plane, hundreds of reporters were at the scene. After 24 hours, that number had doubled. In those first hectic hours County Executive Gaffney provided them with the absolute latest developments. Still, many were unsatisfied. Some tried to contact the families of the victims, who were being housed at a hotel outside Kennedy Airport. Police officers shielded family members from the press while information on the disaster was being assembled.
Natural disasters such as severe storms can often be foreseen and are therefore dealt with more easily. In an unforeseen disaster such as Flight 800, planning is the key. Past incidents around the world had demonstrated the chaos that arises as a result of the failure to control response efforts and access to the scene. Following the downing of Flight 800, these problems were almost nonexistent due to the intensive planning and training undergone by emergency personnel.
Under the direction of County Executive Gaffney, local, county,and state agencies worked with the Coast Guard to establish a unified IMS within an hour of the incident. This multiagency coordination is critical to a successful outcome. In general, the response to TWA Flight 800 was exceptional. The dedication and involvement of personnel exceeded all expectations. And, as FBI and NTSB officials testified, the coordination during the Flight 800 tragedy was unparalleled.
Throughout the evening and into the following morning, County Executive Gaffney was at the scene monitoring and coordinating the entire situation. It wasnít until 6 a.m. on July 18 that officials from the FBI and the National Transportation Safety Board arrived on the scene and assumed control of the operation.
Contact: Lori Benincasa, Director of Health Education and Public Information, Suffolk County Department of Health Services, 225 Rabro Drive East, Hauppauge, NY 11788. Telephone: (516)853-3009. Fax: (516)853-2927.
NEW YORK AND THE BRONX |
Introductory Profile
Maureen is pregnant and due to deliver her baby soon. Itís a high-risk pregnancy, and her blood pressure has been elevated. In a HIP-affiliated New York Medical Group (NYMG) waiting room, the receptionist mentions that she has missed some of her prenatal visits. In a halting voice, Maureen tells the receptionist, who is newly trained in domestic violence recognition, that her husband is tired of her, screams and curses at her, and plans to take the child and refuses to support her once the child is born. The receptionist mentions this event to Maureenís doctor. Both the receptionist and physician were trained through the Partnership to Prevent Domestic Violence, a project of HIP/Victim Services Inc., to recognize that domestic violence occurs in one in four pregnant women. The NYMG doctor asks Maureen a key question: ìAre you safe at home?î Maureen says that she is not, but that she does not want to leave her husband before the childís birth. Together, she and her doctor call their domestic violence care manager, who is also part of the Partnership to Prevent Domestic Violence. Later that day the care manager meets with Maureen for the first time. She will help Maureen devise a safety plan to cope with her husbandís abusive behavior and will meet with her weekly to boost her self-esteem, link her with free legal information on her rights to custody and child support, and help her join a support group for victims of domestic violence. Maureen is doing better. Sheís making all her prenatal visits, is under less stress, and knows that she has options as she awaits her babyís birth and makes plans for their future.
Mission/Purpose
In 1996 Health Insurance Plan of New York (HIP) and Victim Services (VS) initiated a unique collaboration designed to foster innovative and cost-effective responses to domestic violence in health care settings. On August 1, 1997, the two announced the beginning of a groundbreaking three-year project designed to identify and treat victims of domestic violence and their families. Together, the two agencies are designing and implementing a multidisciplinary services strategy targeted to more than 186,000 HIP members and hundreds of affiliated physicians in Manhattan and the Bronx. Patients identified by their primary care providers through the partnershipís screening and assessment protocols will have access to an integrated network of medical, mental health, and community-based services and to continuous follow-up care. Major funding of this phase of the partnership is provided through grants from HIP and from the Robert Wood Johnson Foundation Local Initiatives Funding Partners Program, with additional support from the Chase Manhattan Bank and the New York State Department of Health.
Domestic violence is a major public health crisis, affecting 2 to 4 million women annually from all socioeconomic groups. As one of the few services battered women regularly seek, the health care system offers a strategic opportunity to help victims obtain support and assistance. More than one in ten adult women seen in an ambulatory care setting are involved in an abusive relationship, and studies indicate that as many as one in four pregnant women seen for prenatal care are so involved. These rates are as high as those for women seen in emergency rooms, where domestic violence screening is an emerging practice. However, despite the role that domestic violence plays in causing or exacerbating medical conditions ranging from asthma and gastrointestinal disorders to high-risk pregnancies, most primary care providers are not prepared to identify or respond to the many victims of domestic violence who cross their thresholds.
To address this potent health problem, HIP Health Plans, New York Medical Group affiliated with HIP, and Victim Services began a yearlong pilot project at the NYMG Manhattan West Center and HIPís Manhattan Mental Health Center. During the pilot, NYMG and HIP providers were trained to identify possible victims of abuse and refer them to a partnership care manager who worked exclusively with HIP patients. The care managers, who are Victim Services employees, in turn, provided patients with ongoing educational counseling, information, referrals, and advocacy. The response of patients and providers confirmed that domestic violence requires coordinated treatment responses on many levels. It also pointed to the need to move beyond the current strategy of medical screening and referral out to social services. Therefore, HIP and VS began to think about ways to expand the effort and serve victims identified through the screening with the most appropriate services. In the fall of 1997 the project was expanded to three years and to encompass all HIP centers in Manhattan and the Bronx. The goal of this project is to improve the physical and emotional well-being of HIPís members who are involved in domestic violence. It is being accomplished through the design and development of an integrated domestic violence service strategy that emphasizes prevention and harm reduction by anticipating patterns of coercive behaviors experienced by victims. The strategy will consist of:
- client-centered, outcome-oriented treatment guidelines for providers to use in treating victims of domestic violence and their families
- a network integrating medical and mental health services with community-based services
- case coordination for HIP patients to ensure timely access to appropriate, coordinated, and continuous network services
- training and ongoing technical assistance for all NYMG staff
The project will consist of three phases:
Phase One: A multidisciplinary development team including senior clinical administrative staff from HIP, NYMG, and Victim Services met regularly to design the integrated service strategy, a set of practice guidelines, an integrated service network, and the role of three care managers who will work with providers and patients.
Phase Two: Involves introducing the program to NYMG staffs through training sessions designed by the development team and conducted by Victim Services.
Phase Three: Will begin in the fall of 1998 and extend through the fall of 2000, during which time the intervention strategy will be fully implemented at each NYMG center.
Physician and Support Staff Training
Training of doctors and support staff began in March 1998. By June 1, 1998, it is anticipated that 130 doctors in every NYMG center in Manhattan and the Bronx will have been trained. Physicians are trained in domestic violence screening, documentation, and intervention; the medical effects of domestic violence; and the referral process by which patients are assigned to a partnership care manager who will provide supportive counseling, facilitate access to domestic violence services, coordinate the care of the patient, and refer back to the physician for additional medical referrals. Mental health practitioners receive similar training, but the focus is on the psychological impact of domestic violence. Other staff members learn about the prevalence of domestic violence and how they can assist the partnership by flagging suspected cases.
Nationwide, key medical and public health policymakers have come to the consensus that domestic violence poses a significant health risk and is worthy of attention both in medical practice and in public health initiatives. As early as 1985 Surgeon General Koop convened a high-level working group, which identified domestic violence as a key public health concern. In 1992 the American Medical Association issued diagnostic and treatment guidelines for domestic violence. Similarly, the American College of Obstetrics and Gynecology and the Joint Commission of Accreditation of Healthcare Organizations have recognized domestic violence as a serious problem among their patient population.
For more than 50 years HIP has dedicated itself to the advancement of one class of high-quality health care, with an emphasis on primary care and prevention. HIPís pioneering accomplishments have been officially recognized by the most prestigious health care rating services. HIP provides grants, sponsorships, and direct contributions to a wide range of community -based nonprofit organizations to enhance access to health care and related social services, especially for the disadvantaged, elderly, children, and young adult populations. It believes that it has a responsibility to take a leadership role and takes that self-imposed obligation very seriously.
Leadership Role
The Partnership Project is being conducted jointly by a team under the overall leadership of Moishe Labi, M. D., medical director of NYMG; Mary Bleiberg, the original Victim Services program director, who was succeeded by Terri Pease, Ph.D.; and Carmen Verdejo, HIPís managing director of external affairs, who serves as HIP project coordinator.
The Team
A multidisciplinary team including senior medical, mental health, and administrative staff from HIP, NYMG, and Victim Services met regularly during the first six months of the project (September 1997 to February 1998) as the development team. It began by analyzing the medical records of patients who had been served in the pilot project and by sharing the distinct perspectives of its constituents on how to best care for these patients.
Practice Guidelines
Out of these discussions the team created a set of practice guidelines that include treatment goals, the methodology used to achieve those goals, and a common language for all providers to use. It also planned the logistics of implementing the service strategy, beginning with the training of all of NYMGís primary care doctors in the two target boroughs, Manhattan and the Bronx.
Care Managers
The development team also designed the role of care managers, who work with providers and patients to secure the most appropriate mix of services within the network or to help clients obtain needed services elsewhere. The care managers are also responsible for coordinating the flow of information among network providers as well as monitoring patient utilization and quality assurance and assisting providers in using the practice guidelines.
HIPís Expertise
While the teamís next effort will be to create an integrated service network that includes new interventions focused on early identification and concrete services, HIPís Medical Economics and Data Analysis department is providing the technical assistance needed to allow Victim Services to develop actuarial data for cost models of these servicesóa key component to ensure that the strategy is one that can be extended to the wider marketplace.
This project has been a true partnership of HIP, NYMG, and Victim Services. These organizations have worked together closely to evaluate the initial pilot project and determine how to proceed with its expansion. Beyond the substantial financial commitment required to support the effort, additional HIP resources have been made available to ensure the projectís success. HIPís Medical Economics and Data Analysis department helped to design the patient record form and provided appropriate access to patient and provider data in order to assess the effectiveness of the intervention protocol and discern utilization and clinical profiles that characterize battered women. HIP and NYMG staff have also been active in familiarizing the care managers and other Victim Servicesí staff with the functions of their employees and centers. NYMG system coordinators have given technical assistance to the care managers within the centers and with patients. Victim Services has, in turn, trained HIP and NYMG about domestic violence and has been an active force in coordinating day-to-day care of patients recognized through the screening and care guidelines, linking them with the wide range of publicly funded services available through the organization.
Key Partners/Stakeholders
Representatives from HIP include: Arthur H. Barnes, Senior Vice President for External Affairs; Carmen Verdejo, Managing Director of External Affairs; Mark Schachter, Vice President, Medical Economics and Data Analysis; Neil Meyerkopf, M.B.A., M.S.W., Director, Mental Health Services; Suzanne Appel, M.D., Director, HIP Manhattan Mental Health Center; and David Yokell, M.D., Director, HIP Bronx Mental Health Center.
Representatives from the New York Medical Group included: Moshe Labi, M.D., Medical Director; Joseph Zeitlin, M.D., Chair of Quality Improvement; and
Maria Bazdekis, Director of Quality Improvement.
Representatives from Victim Services included: Michael Kaiser, Associate Director, Development and External Affairs; Mary S. Bleiberg, Program Director, Partnership to Prevent Domestic Violence; Terri Pease, Ph.D., Deputy Program Director, Partnership to Prevent Domestic Violence; Nigel Ferguson, Partnership Program Assistant; Connie Boris, Care Manager; and Wanda Vasquez, Care Manager.
The Need
Domestic violence occurs in all walks of life. No social group is free of it. And HIP, whose affiliated medical groups in the Bronx and Manhattan care for New Yorkers from a very broad range of class, ethnicity, and economic strata, has come to recognize that the partnershipís services are needed in every area. The makeup of the participants in the partnership, including HIP, NYMG, and VS senior staff, the partnership care managers, and NYMGís professional and support staff, encompasses the natural diversity that is part of the social and ethnic fabric of New York City. The partnership staff is prepared to work with patients from New Yorkís large Spanish-speaking communities and can link other patients with specialized domestic violence services in a range of languages from Hindi and Greek to Cantonese and Russian.
Cultural Differences
The training curriculum strives to be inclusive of the multiple cultures represented in the HIP membership and to take into account the cultural influences on domestic violence in order to offer appropriate, sensitive responses to these influences. This includes an awareness of abuse in gay and lesbian relationships, abuse of elders and of teens in relationships, and the needs of men abused by women, as well as the ways in which immigration status, class standing, and membership in minority communities might have an impact on oneís ability to access domestic violence services.
While domestic violence has an impact on all aspects of patientsí well-being, much of the intervention that is needed can come from mental health and behavioral health care providers. HIP has, as the centerpiece of its response to patientsí mental health needs, community-based mental health centers in the Bronx and Manhattan. In addition, HIP has developed a network of independent mental health providers in the two boroughs, and throughout New York City, who meet more specialized mental health needs of HIP members. These groups include the Jewish Board of Family and Childrenís Services (JBFCS), Fordham-Tremont Mental Health Center, the Ackerman Institute, the Karen Horney Institute, and many others. Network providers also work with the Partnership to Prevent Domestic Violence care managers to ensure that membersí needs for psychiatric and substance abuse treatment are addressed in an appropriate manner.
HIP has medical centers located in New York Cityís other three boroughs. Informal contacts with HIP social workers in other boroughs demonstrate their eagerness to make use of the partnershipís specialized services for the domestic violence patients they have already identified. As the intervention strategy is refined and shown to be effective, the Partnership can be expanded to encompass all of New Yorkís boroughs, as well as similar HMOs in other parts of the country.
Although day-to-day decision making is left in the hands of the program director, the partnership is organizing an advisory board of healthcare providers and experts in the field of domestic violence, including Robert McAfee, M.D., past president of the American Medical Association, and Dr. Anne Flitcraft, pioneer in the field of domestic violence.
The development team is charged with creating the integrated service strategy, which includes the intervention protocols and practice guidelines, a network of care providers, the care management system, and training and technical assistance for providers. This team meets regularly to review the partnershipís progress to date, to discuss policy, strategize future activities, and to confront any emerging difficulties in project implementation. In addition, frequent informal communication among the members of the development team has been a hallmark of the partnership and has been key in moving the effort forward.
HIP Health Plans
HIP provides corporate leadership for the project, which includes its ongoing commitment of funds and technical assistance from its legal, quality improvement, data analysis, and public affairs and external affairs departments. HIPís director of medical economics and data analysis is a member of the development team. This department has been collaborating with Victim Services to construct an evaluation and to analyze the projectís outcome data. HIP Mental Health provides an integral part of the service delivery system. Recognizing the complementary nature of their work, domestic violence screening and referral to and collaboration with the care managers have become institutionalized as important elements of their practice.
New York Medical Group
NYMGís 130 primary care physicians are the backbone of the project. Their responsiveness to training and openness to adopting domestic violence screening as a new medical practice constitute the sine qua non of the partnershipís success. Unless doctors ask patients, ìAre you safe at home?,î there are fewer patients to treat and more victims surviving in isolation. The administrators and medical directors of the 15 NYMG and 2 mental health centers have encouraged these physicians to screen, identify and refer patients, and maintain the supportive public education materials at each site. The site administrators also facilitate and coordinate the training of employees at each center.
Victim Services
VS is responsible for the day-to-day operations of the Partnership to Prevent Domestic Violence. It coordinates the entire program, including scheduling and managing the training, convening the development team and advisory board, supervising the care managers, soliciting funding, and taking care of the administrative details of the partnership. The care managers receive referrals from the doctors and patients (95 percent of referrals involve females) and then meet with each referred patient to determine the level of risk she or he is facing and develop an intervention plan. This frequently includes creating a safety plan, either for escape or for harm reduction. The care managers are also responsible for providing written comments to the referring doctor or therapist regarding the patientís progress. Their work with doctors includes scheduling case conferences as appropriate, encouraging physicians to screen, and providing technical assistance.
Impact/Effectiveness
The partnership has trained 157 doctors in 15 centers that serve over 186,000 members. Of these members, 69,000 are women between the ages of 15 and 65, who are at greatest risk for domestic violence. It is anticipated that the project will result in a greater number of physicians who are aware of domestic violence and routinely screen for its presence among their female patients (abuse occurs in male patients too, and doctors are being trained to recognize this as well). More patients and providers will be aware of the health consequences of domestic violence, and a greater number of battered women will be identified by their physicians and have access to supportive services. Additionally, the partnership expects evaluation to show that utilization of medical resources will improve by considering domestic violence as a potential cause of injury and illness. The physical and mental health status of patients identified and served should also improve.
It also anticipates that the identified patients will be less likely to seek emergency shelter and less likely to abuse drugs and alcohol. The project will be evaluated in several phases, including a pre- and post-test of physicians about their knowledge of domestic violence and screening rates, an analysis of the medical and social service utilization rates of battered women before and after they have been identified, as well as an examination of the physical and mental health of victims. There will also be focus groups with physicians to determine the accessibility and usefulness of the training and identification protocol.
HIPís Commitment
The integration of a social service intervention into a health insurance companyís network of services has the effect of redefining the meaning of health care in the New York City area. The commitment of HIP and NYMG to respond to the issue of domestic violence without requiring that programs operate under the constraints of showing cost or utilization reductions has allowed the development of a wholly new intervention. While that intervention may ultimately result in reductions in costs, by funding and supporting the partnership, HIP has demonstrated commitment to address the well-being of its members, recognizing that domestic violence takes a toll on all who are involved: the members who are victims, their partners (who are often also HIP members), and the children in their families. The primary benefit to HIP arises as more women are identified as being in abusive relationships and are given access to social services for themselves and their children, resulting in a reduced risk of injury and illness.
NYMG Physicians
NYMGís physicians also gain. As they know more about domestic violence and its potential health problems, they will experience improved diagnostic precision and become more cognizant of the difficulties faced by patients in abusive relationships. They will recognize situations in which medical noncompliance is indicative of a patientís abusive home environment and, by being aware of appropriate referral procedures and services, theyíll be in a position to offer immediate and effective help to abused patients.
HIP and NYMG are able to provide improved services for patients and achieve greater satisfaction with their health plan. There is a potential reduction in inappropriate medical utilization, and the improved physical and mental health status of their patients improve as a result of early intervention in cases of domestic violence.
Victim Services
VS gains experience in working with clients who are identified earlier in the course of a violent relationship and is able to reach clients who otherwise might not seek services. In addition, the agency has the opportunity to pioneer new domestic violence interventions at sites where clients are less reluctant to acknowledge their need for help.
Primary funding for the partnership has come from HIPís Department of Corporate External Affairs. Additional funding comes from the Robert Wood Johnson Foundation Local Initiatives Funding Partners Program. These funds pay for staff resources provided by Victim Services. HIP/NYMG staff, especially the medical directors and site administrators, have played a key role with program implementation and by endorsing the use of the protocol and practice guidelines. In addition, the rich variety of Victim Servicesí publicly funded programs for victims of domestic violence are available to those identified through the partnership. The care managers help patients to access advocacy services, assistance in filing for Orders of Protection, emergency housing transfers, emergency financial assistance, lock replacement, crisis intervention through the domestic violence hotline, support groups at community offices, and shelter for themselves and their children.
Even before the partnership began, HIP showed its commitment to the issue of domestic violence by underwriting the cityís bus and subway poster campaign advertising the Domestic Violence Hotline. Since that time, HIPís commitment to address domestic violence in a bold and proactive manner has been recognized throughout the entire HIP organization. Dramatic positive steps have been taken to address domestic violence as a serious health problem. By agreeing that HIP support staff be trained along with affiliated NYMG physicians, sensitivity to domestic violence is becoming part of the HIP culture. Furthermore, a patient education campaign utilizing attractive brochures and posters advertising the HIP/VS partnership lets HIPís members know that the HIP-affiliated center is a place where safety at home is taken seriously and where knowledgeable staff at all levels will respond to their needs for information and for help. This type of education about the project and about domestic violence encourages those who have not yet been identified to self-refer to the partnership care managers.
Although the current partnership is only a year old, it has already had significant success and developed a variety of products that are being integrated into HIP and NYMG. They include:
- clinical practice guidelines and intervention protocols for both medical and mental health care
- development of a unique care management function to track a patient from the time domestic violence is identified and coordinate medical, mental health, and social service interventions
- a one-hour training curriculum for both physicians (with CME credit) and support staff that introduces domestic violence, the practice guidelines, and intervention protocols
- a domestic violence client record that facilitates careful tracking of patient progress and coordinated reporting to referent and primary care providers
- public education materials that include posters, buttons for physicians, a palm card, and brochures that ask ìAre You Safe At Home?î
- a newsletter that is distributed to HIP staff and physicians, giving more details about the partnership and highlighting successes from across the HIP centers
In the early stages of development are intervention groups to be held at the NYMG centers. These groups will be operated on a drop-in basis, allowing anyone to partake of them. The groups will cover topics such as parenting under stress, relationship issues, and managing the stress of caregiving. They will be designed to address domestic violence and family abuse without the negative connotations of those particular words.
There have been nearly 120 referrals; at least half of these women have children who are also HIP members. Children are also assisted through the partnership, with services including safety planning and referrals to social services and mental health treatment.
The Hidden Factor
Traditionally, domestic violence has been a hidden, private matteróthe concern of only clergy, family members, or marriage counselors. This hidden factor has kept some, including doctors, from recognizing that domestic violence is a widespread problem and a contributor to significant health problems for its victims. Physicians thus may be reluctant to speak about domestic violence with their patients for fear of offending them, although studies have shown that patients would prefer that doctors ask about violence and see this intervention as well within the physicianís sphere of concern. Doctors also express reluctance to address domestic violence because they doubt there is enough time during the appointment to address the issue and/or they do not have confidence in the patientís access to resources. Overcoming this reluctance has been a significant challenge to be met by the partnership.
Shelter for Victims
Shelter beds in New York City are limited and cannot accommodate every victim of domestic violence who might want shelter. Fortunately, the partnershipís early intervention strategy tends to identify cases of domestic violence before the radical step of seeking emergency shelter is needed. Still, not every patient who needs shelter is assured of an immediate shelter placement, and this challenge is one that affects any program that identifies and serves victims of domestic violence.
Access to the Program
Access to the Partnership to Prevent Domestic Violence begins with a patientís membership in HIP. When a battered woman divorces a husband who is the primary health insurance subscriber, she could lose her health insurance. This creates a paradoxical situation in which the partnership intervention may have facilitated the loss of a victimís health insurance. Responding to this challenge is a task that the development team will face in the immediate future.
Addressing the Abuser
Another thorny issue yet to be faced is the problem of recognizing and responding to the needs of the HIP member who is abusive to his or her partner. Programs for abusers are far more scarce than those for victims. The partnership will need to address patients who will invariably become more visible as victims are increasingly identified and helped.
HIP Health Plan Contact: Carmen V. Verdejo, Managing Director, HIP Health Plans, 7 West 34th Street, New York, NY 10001. Telephone: (212) 630-8578. Fax: (212) 630-8616.
Victim Services Contact: Terri Pease, Ph.D., Program Director for the Partnership to Prevent Domestic Violence, 2 Lafayette Street, 3rd Floor, New York, NY 10007. Telephone: (212) 577-1369. Fax: (212) 577-7355.
Available Publications and Materials (HIP and Victim Services joint authorship):
ìAre You Safe at Home?î Brochure, poster, palm card, buttons; Physicianís ìTip Cardî
OCCUPATIONAL SAFETY AND HEALTH |
Mission/Purpose
The Rochester Council on Occupational Safety and Health (ROCOSH) is an organization of labor, health, and legal professionals and others working together to improve the health, safety, and environmental conditions for workers in the greater Rochester area. Its mission is to prevent occupational injury and disease by giving people the knowledge, information, and skills they need to make Rochester-area workplaces safer. The councilís philosophy is to focus on workplace leaders who are in a position to bring about changes that will affect many workers. ROCOSH was founded in 1981 by a group of union members, physicians, and educators, who organized several conferences on occupational safety and health and provided technical assistance to area unions. It has maintained an office and paid staff since 1986. ROCOSH is a nonprofit organization, operating with funds from grants, individual and union membership dues, and donations. Membership includes 47 unions, 16 organizations, and 103 individuals.
Trainings, Workshops, and Seminars
ROCOSH provides high-quality, low-cost, practical training in the field of occupational health and safety. Its workshops range from trainings designed to address the specific hazards faced by particular unions to public programs on topics of broad interest to labor and the community. Examples include: fall protection; art hazards; chemical hazards of fire fighting; back injury prevention; workplace violence; stress/wellness; repetitive motion injury prevention; health hazards of lead; controlling workplace noise; office ergonomics; health hazards of physical plant workers; lock-out/tag-out; confined space; blood-borne pathogens; indoor air quality; TB in the workplace; chemical hazards of waste water workers; leadership development; collaboration for a democratic workplace; advocacy/ empowerment; workplace hazard evaluation and monitoring; effective communications; personal protective equipment; integrated pest management; asbestos awareness; health and safety representative training; health and safety committee training; understanding Workersí Compensation; OSHA 10-hour construction course; and OSHA 10-hour industry course.
Other Programs and Activities
ROCOSH maintains a library of reference materials on occupational health and safety issues, including weekly updates of OSHA-related information. Through a newsletter, targeted educational mailings, and mass media, ROCOSH provides information on occupational health and safety issues to its membership and the general public.
By phone and in person, ROCOSH provides referrals, advice, and answers to questions about workplace hazards, occupational diseases, health and safety regulations, Workersí Compensation, and related topics. ROCOSH works on an ongoing basis with unions, individuals, and health and safety committees to help them address these health and safety hazards. ROCOSH engages consultants to address specific health and safety problems. For example, industrial hygiene consultants are hired to deal with problems of indoor air quality.
In addition to training, information, and technical assistance, ROCOSH provides staff support (through such efforts as ROCOSH Injured Workers Group support program) to empower union and community members to bring about changes in attitudes and beliefs that will lead to more humane societal and organizational practices, thus eliminating or reducing workplace health and safety problems.
ROCOSH conducts research on issues related to occupational health and safety. It is currently working in collaboration with the Finger Lakes Occupational Health Services of the University of Rochester School of Medicine (FLOHS), Cornell University School of Industrial and Labor Relations, and the University of Toronto Centre for Applied Social Research to research issues of occupational stress.
This research agenda is particularly focused on the institution of democratic workplaces in order to bring about organizational and societal practices that can eliminate or reduce the negative human and organizational consequences arising from occupational stress.
Examples of Recent Programs
General Trainings
ROCOSH provided training for New York State teachers. The training included the fundamentals of indoor air environment, including the source of problems; typical health symptoms related to poor quality air; and how occupants and building materials can be affected. The training consisted of a lecture with handouts. Training was conducted by Bill Benet, M.S.Ed., Res. Dip. S.W. Thirty-five participants attended the one-hour training.
ROCOSH provided training for individuals with occupationally related chronic health conditions due to an injury or disease. The program consisted of six two-hour sessions. Training included pain management, assertiveness and effective communication, redefining self, and other issues of concern to injured workers. Training consisted of a lecture, small-group exercises, and discussion. Training was conducted by Alice Armstrong Rahill, Ph.D., a neuropsychologist with the Finger Lakes Occupational Health Services. Four participants attended each session.
ROCOSH provided training to Rochester Institute of Technology professors on safety and health issues surrounding sweatshop conditions and child labor . The training addressed inadequate enforcement of OSHA safety and health regulations in sweatshops, the employment of young children, and actions participants can take to improve enforcement. Training was conducted by Bill Benet. The one-hour training consisted of a lecture, overheads, and discussion. Twenty participants attended.
ROCOSH provided training to labor unions, politicians, and members of the community on safety and health issues surrounding sweatshop conditions and child labor. The training covered inadequate enforcement of OSHA safety and health regulations in sweatshops, the employment of young children, and actions participants can take to improve enforcement. Training was conducted by Bill Benet. The one-hour training consisted of a lecture and was attended by 75 participants.
ROCOSH provided training for waste water treatment operators at the Monroe County Water Authority. The training covered basic toxicology, hazard communication, Right-to-Know and Material Safety Data Sheets, and hazards of specific chemicals. Training consisted of a lecture, discussion, and small-group exercises. The one-hour training was conducted by Jean Douthwright, Ph.D., professor of biology at the Rochester Institute of Technology, and 12 participants attended.
ROCOSH provided training for Rochester Labor Council officials and delegates. The training addressed the importance of safety and health in the workplace, employee rights under OSHA, and organizing around the issue of safety and health. Training was conducted by Bill Benet. Training was one hour, with 75 participants attending.
ROCOSH provided training for union members and community members. The training covered the importance of safety and health in the workplace and employee rights under OSHA. Training consisted of a lecture and a question-and-answer period. The one-hour training was conducted by Bill Benet, with 125 participants attending.
ROCOSH provided training for the Rochester Institute of Technologyís Economic Education Center. Training consisted of a lecture and handouts, with time for questions and answers. The training covered the impact of world economics on workplace safety and health. Nineteen participants attended the one-hour training.
ROCOSH provided training to Cornell students in the ILR Contract Administration Course. Training covered introduction to OSHA, employee rights under OSHA, bargaining for safety and health in contracts, and overall issues of safety and health in the union movement. Fifteen participants attended the one-hour training conducted by Bill Benet. Training consisted of a lecture with handouts.
At the New York State Occupational Health Clinic Network Health and Safety Conference, ROCOSH provided information on the Injured Workers Support Group, which is sponsored by ROCOSH and the Finger Lakes Occupational Health Services. Training was conducted by Koralee Bernardo, program director for ROCOSH. The two-hour training consisted of a poster presentation with a question-and-answer format. Topics included stricter enforcement of OSHA regulations in the workplace, status on OSHA ergonomics standard, and Workersí Compensation. Eighteen participants attended.
ROCOSH provided information to the community on potential development of improved occupational health and safety practices through worker-owned cooperatives. The training covered introduction to OSHA, employee rights under OSHA, OSHA enforcement problems, and worker-owned cooperative strategies for improving occupational health and safety conditions. Training was conducted by Bill Benet. The two-hour training consisted of a lecture followed by a question-and-answer period. Thirty-eight participants attended.
ROCOSH Injured Worker Programs
Each session was two hours and consisted of a question-and-answer plus lecture format.
ROCOSH and the Finger Lakes Occupational Health Services provided a workshop on Workersí Compensation. Panelists included Lani Bauer, a social worker with the Rochester Workersí Compensation Board; attorney Steve Modica; and Bill Benet, executive director of ROCOSH. Nineteen people attended.
ROCOSH and FLOHS provided a workshop for injured workers on VESIDó the Vocational and Educational Services for Individuals with Disabilities Agency. Lori Baumann, senior counselor with VESID, was the guest speaker. Topics included VESIDís services and how to get started. Six people attended.
ROCOSH and FLOHS provided a workshop for injured workers. The guest speaker was local labor attorney Matt Fusco. Topics included when to file a claim for Workersí Compensation, how to get the benefits you deserve, what happens when claims are denied, and how claimants can work effectively with their attorney. Sixteen people attended.
ROCOSH and FLOHS provided a workshop with three panelists to address issues raised by injured workers who are receiving Workersí Compensation. Topics included definition of doctors and terms, how to get timely medical reports, and patient rights. Panelists included Dr. Bill Beckett, medical director of FLOHS; Lanie Bauer, a social worker; and an injured worker. Five people attended.
ROCOSH and FLOHS provided a training on handling personal finances while on Workersí Compensation. The workshop was conducted by Joanne Schroeder, director of education, Consumer Credit Counseling Service. Topics included debt attack plans, prioritizing bills/debts, and ways to increase income and reduce expenses. Three people attended.
ROCOSH and FLOHS sponsored a workshop on federal disability benefits. Paralegal Anne Lang was the speaker. Topics included how to apply for SSDI/SSI benefits and what to expect. Five people attended.
ROCOSH and FLOHS provided a workshop on dealing with chronic pain. Dr. Alice Armstrong Rahill was the guest speaker. Topics addressed the development of effective coping skills, the identification of limitations on the job and around the house, and the use of exercise in coping with chronic pain and handling physical and psychological changes. Five people attended.
ROCOSH and FLOHS provided a workshop on chronic fatigue and sleeplessness. Dr. Rahill was the guest speaker. Topics dealt with issues and concerns surrounding chronic fatigue and sleeplessness related to chronic pain. Four people attended.
Summary of 1997ñ1998 Activities
ROCOSH conducted a total of 71 training programs from July 1997 through June 1998; a total of 844 individuals attended. Technical assistance was provided to a total of 257 people, and a series of ten newsletters were distributed to an average of 500 people per mailing.
Contact: Bill Benet, M.S.Ed., Res. Dip. S.W., Rochester Council on Occupational Safety and Health (ROCOSH), 46 Prince Street, Rochester, NY 14607. Telephone: (716) 244-0420. Fax: (716) 244-0956. E-mail: BillBenet@aol.com
1997 PARTNERS IN RURAL TRAFFIC SAFETY |
Mission/Purpose
The purpose of the Partners in Rural Traffic Safety Program was to reduce the number of traffic-related injuries and fatalities in rural areas through a community involvement program. The goals included (1) increasing the use of seat belts in the village of Candor and (2) raising awareness of issues regarding occupant protection devices, such as proper use of infant and car seats and air bags. This program focused on the priority action area of ìunintentional injury.î
The project began when the National Rural Health Association announced the 1997 Partners in Rural Traffic Safety Program in April 1997. Dean Mary Collins and Dr. Pamela Stewart Fahs, assistant professor of the Decker School of Nursing (DSON), Binghamton University, approached the Tioga County Health Department about identifying a rural community in which traffic safety was an issue. The village of Candor was identified by Wanda Wanck, health educator, and Gail Rhodes, director of patient services at the Tioga County Health Department (TCHD). The village of Candor met the community size guidelines (fewer than 2,500 residents) of the funding agency and was a community whose residents were interested in the issue of traffic safety and were willing to work as a team to increase seat belt use. Mayor Chad Showers and Chief Damir Lazaric of the village of Candor helped identify the community team members. These individuals represented six sectors, including health care, law enforcement, business, places of worship, education, and the community at large. Thus, a successful collaboration was forged when the people of the village of Candor, the Tioga County Health Department, and Binghamton Universityís Decker School of Nursing, came together to write a proposal for the 1997 Partners in Rural Traffic Safety Program. The Partners in Rural Traffic Safety Program was conceived and administered by the National Rural Health Association (NRHA) and sponsored by the National Highway and Traffic Safety Administration (NHTSA).
The Candor Partners in Rural Traffic Safety Community Team was one of four initial grants provided by NRHA and NHTSA. The community received $2,000 to fund a monthlong traffic safety intervention program.
Strategies to Build Consensus
After the project had been funded, each community sector representative identified community members and invited them to a 11/2 hour ìcommunity visioningî session in July 1997. A nominal training strategy was used at this session in order to gather community insight into the issue of traffic safety, specifically focusing on seat belt use. In addition to the team itself, approximately 20 community members attended the visioning session. They ranged from 10 to over 70 years of age. The group was asked to identify the barriers and benefits to using seat belts. Small groups were assigned to identify ways to increase seat belt use in the village of Candor. Each group came up with a list of ideas, negotiated, and voted for five ideas to be presented to the overall group. A master list of these ideas was placed on sheets of newsprint, and each community member was able to ìvoteî by placing sticker dots beside the idea or ideas he or she preferred. The ideas receiving the most votes were considered a high priority for inclusion in the intervention.
Interventions Chosen by the Community
The community-generated suggestions included:
- displaying a banner over the street
- the ìConvincerîóstate police
- road stops/spot checks with warnings leading to tickets
- giving fact sheets to drivers
- an awareness day
- target information for each audience
- poster contest, displaying winners and awarding small prizes
- parent awareness video about car seats
- Vince and Larry dummies
- event for checking child seat installation
- mock seat belt activities for preschool
- encourage young children to use seat belts
- give awards for seat belt use
- encourage health providers to ask all patients if they wear their seat belts
- encourage drivers to say ìMy car doesnít go if all the seat belts arenít buckledî
- statistics brochure to be distributed to the public
These suggestions were used by the Partners in Rural Traffic Safety Community Team in the planning of the monthlong intervention program.
Consensus of Service Providers, Public, and Key Policymakers
The community visioning session brought together a variety of ìplayersî and made the planning process inclusive. Many of these players were citizens who would not have been consulted in a more traditional planning scheme. The public health department had identified reducing the number of unintentional injuries as a goal in their 1997 assessment, and this project worked toward achieving that goal. Two members of the community team (education and worship) were also members of a countywide traffic safety committee and felt that this project fit well with the goals of that committee. The DSON is interested in the health of rural citizens and is actively involved in issues of rural health care.
Vision of a Healthy Community
The Candor Partners in Rural Traffic Safety saw this project as an opportunity to bring together the entire community to work on what is essentially a public health issue. The teaming of health care and law enforcement in a prevention activity was an unusual but successful aspect of the project.
Leadership Role
Type of Leadership Structure
The collaboration among the major players (village of Candor, TCHD, and DSON) was forged to write a successful grant application. Faculty from the DSON wrote the grant application with a great deal of input from the mayor and police chief of Candor and the TCHD. This collaboration continued as representatives from each of the major players as well as the six sectors were included in the formation of the community team. The actual running of the team was very much a collaborative process. A natural leader from the community emerged who helped move the meeting agenda forward. The school of nursing representative helped formulate the agendas, communicated with the funding agency, and generally facilitated the actions of team members as needed. Team members divided portions of the planned interventions among them and went to work on securing resources and making it happen. Progress on goals was reported to the team at each planning meeting.
Technical Assistance
A representative from the NRHA and a ìteam builderî from a consulting firm hired by NRHA to implement the nationwide program came to Candor in late July 1997 for two days of team building skills. They helped the team members to identify team strengths and potential weaknesses, worked on ìcommunity visioningî skills, and assisted as the team carried out the community visioning session. They also worked with a group of residents identified by the community team on how to carry out the ìindex surveyî of seat belt use.
Jim Allen of the New York State Governorís Traffic Safety Committee assisted in getting past some of the barriers to securing resources such as posters, coloring books, the Vince and Larry costumes, and the Convincer. His office was also helpful to the mayor in deciding how to get permanent signs that focused on increasing seat belt use in the community. C-Troop of the state police was helpful by being at the awareness day, bringing and running the Convincer, and talking to citizens about the importance of seat belts. The TCHD provided a great deal of technical assistance and resources, sending their health educator to various sites to assist with identification of properly installed car seats, and making the ìmake it clickî program available for use with preschoolers. This representative also served on the community team as a resource and worked diligently toward the campaign goals. The DSON provided technical assistance and resources in encouraging a faculty member to write the grant and to participate on the community team. In addition, a graduate research assistant was assigned for one semester to work with the faculty on the Partners in Rural Traffic Safety project.
Key Partners/Stakeholders
Principal partners on the community committee, the sectors they represented, and their contributions included the following:
- Health Representative
David Kwiatkowski, M.D., Candor Family Practice Center, distributed age and developmentally appropriate fact sheets to patients regarding seat belt safety and health.
- Business Representative
Eva Musgrave, Owner, Edge of Thyme Bed & Breakfast, worked with the local Chamber of Commerce to build support for the project. She also acquired the town banner, produced and distributed placemats, and advertised events.
- Law Enforcement Representative
Chief of Police Damir Lazaric, Village of Candor Police Department, distributed fact sheets, conducted road stops for seat belt inspections, and provided canine team demonstrations at the safety awareness day.
- Education Representative
Art Cacciola, Candor Central School District, provided photography for the project and worked with the school system. He coordinated the in-school coloring contest and worked with high school students to develop age-appropriate bulletin boards.
- Decker School of Nursing, Binghamton University
Pamela Stewart Fahs, D.S.N., R.N., Assistant Professor, Decker School of Nursing, Binghamton University, wrote the original grant application and helped the community coordinate, carry out, and evaluate the project.
- Tioga County Health Department
Wanda Wanck, R.N., Health Educator, Tioga County Health Department, planned the ìmake it clickî seatbelt practice for preschoolers and worked with registered nurses to develop car seat check program.
- Place of Worship Representative
Elizabeth Grippen, parishioner, United Methodist Church, worked with the religious community to include information in church bulletins, newsletters and so forth, and coordinated the Sunday school coloring contest.
- Community At Large Representative
Chad Showers, Mayor, Village of Candor, chaired planning meetings, coordinated many of the project components, and acquired permanent seat belt signs for the community.
In addition, Wendi Galliger, R.N., Decker School of Nursing graduate student, assisted in carrying out the ìmake it clickî and seat belt checks, and did the data entry for the statistical analysis. Margaret Young, R.N., Decker School of Nursing graduate student, carried out the six-month recheck using seat belt safety index.
Process for Inclusion
Planning meeting times were scheduled so that all members could participate. (It was known prior to the planning meetings that the physician on the team was unavailable for the planning meetings; therefore the nurses on the committee represented the health care sector in the planning process.) Each member chose certain tasks to spearhead; these were often a natural extension based on the sector of the community they represented. For example, the representative from education organized the coloring contest in the school and the setting up of bulletin boards in the high school. The community-at-large representative (the mayor) took care of proclamations and obtained signs for the community. The business representative obtained donations from the Chamber of Commerce and had the banner made.
Students in the local school district assisted in carrying out the planned interventions, i.e., painting signs and helping at the Festival of Safety.
Potential Partners for Inclusion
The health care provider who works on this project in the future should be one who is able to devote the necessary time to the planning process. A nurse or nurse practitioner, emergency squad member, or health educator might be an appropriate representative. The involvement of more adolescents in the process would be beneficial. In addition to participation in the community visioning, an adolescent could provide representation and become an active member of the team.
The group decision-making process was by consensus. In large part this was made easier by the ìcommunity visioning tally, î which guided what would be done in the campaign.
Roles
Each sector representative was given guidance with respect to potential roles. Notebooks were provided at the training session in July containing a ìsample 30-day campaignî with suggestions for each representative. For example, the health care provider was given a notebook that offered suggestions such as writing ìprescriptionsî for using seat belts and making literature on traffic safety and health issues available in the waiting room. The law enforcement officer received material on the use of warning tickets during the campaign as well as reinforcements for the use of seat belts (coupons for goodies at an area fast-food restaurant).
This team proved to be collaborative and fun. It was felt that ideas had come from a cross section of the community and had thus generated increased community interest and participation in the project.
Impact/Effectiveness
Expected Outcomes and Strategies to Evaluate
The expected outcome was to increase seat belt use in the community. This outcome was accomplished. Seat belt use was evaluated by ìindex surveyîóa method whereby strategic sites within the community are chosen and measures are taken for a specific frame of reference. In this case, the team chose 12 sites (locations in the village) during the two-day training session. A volunteer or pair of volunteers took responsibility for one or two sites. A date and time was chosen that best reflected traffic in the area, and the volunteers were given index survey sheets. Volunteers were to observe front-seat occupants at their appointed site on a chosen date precampaign and again postcampaign. They circled Y (yes) or N (no) to indicate whether the driver and passenger of each vehicle were wearing a shoulder belt. Although this may not be the best scientific measure of seat belt use, it met the objectives of the project and succeeded in involving members of the community. The planning team members did not do counts to avoid conflict of interest in measuring outcomes.
Benefits to Partners and Community
The representatives of the three major partners (the village of Candor, TCHD, and DSON) all had a sense of accomplishment in planning and carrying out a community intervention project that was successful yet not overly time consuming. The outside funding assisted in providing seed money and generated the initial excitement that continued and grew as the project took shape and became a reality. One important benefit was that the public health problem of accident and injury from motor vehicle crashes was addressed in a manner that was embraced by the community.
Fiscal and Staff Resources
A grant of $2,000 was awarded to the Candor Partners in Rural Traffic Safety Community Team to assist in planning, implementing, and evaluating this project. The Tioga County Health Department was supportive of the project, sharing its knowledge of existing programs that could be implemented as part of this project and getting a staff member involved (who participated on her own time). Faculty and administration from the Decker School of Nursing spearheaded the forming of the collaborative partners and provided resources (faculty and student time) for the implementation and evaluation of the project. The mayor and chief of police were instrumental in the identification of segment representatives from the village. The segment leaders planned and implemented the project.
Community Support and Efforts
The people of the village of Candor donated many hours of service in the assessment, planning, implementation, and evaluation of this project. The sector representatives were the backbone of this project, truly involved and committed to its goals. The synergy that was created by the three major partners brought together resources and made possible a beneficial project that any one organization alone would have had trouble carrying out. The involvement of the major stakeholders made it possible to avoid the territorial issues that can sometimes generate barriers. In addition, the guidance, team building, and resource support by the funding agency were very helpful in getting the project underway. The community was able to actually implement the project and evaluate the outcomes.
Milestones/Work Products Achieved by the Group
Seat belt index surveys were taken prior to and after the 30-day campaign. Materials for a public awareness campaign were chosen by the community team and ordered from NHTSA and the New York State Governorís Traffic Safety Committee. These materials included posters, fact sheets, stickers, coloring books, and so on. The materials were free and NHTSA waived the shipping fee; however, they were out of stock on many of the materials ordered. NHTSA representatives and Jim Allan from the New York State Governorís Traffic Safety Committee worked with the community team to find material appropriate to the campaign.
Materials were distributed to the local primary care health clinic, the schools, and the library. The team chose the slogan ìCandor CaresóBuckle Up.î The police department gave out warnings and fact sheets for first stops of vehicles whose occupants were not wearing seat belts. A reward of a fast-food coupon was given to those who were. Police road stops for seat belt checks were planned and implemented soon after the campaign. The Chamber of Commerce donated money to have place mats printed with a traffic safety message. These were then distributed to local eateries and restaurants. Businesses in the village and region were solicited for donations to be used in the campaign. These businesses were very generous in their donations.
Coloring contests were sponsored in grades K through 5. The local bank donated savings bonds as prizes for the category winners. Children attending local Sunday schools were also asked to color ìVince and Larryî pictures, which were then displayed. T-shirts with a traffic safety slogan were printed at cost ($5.00/shirt) and distributed to coloring contest participants and at the Candor Festival of Safety. In addition, each restaurant in the village held a T-shirt raffle. A banner stating ìCandor CaresóBuckle Upî and ì30 Days to Build a Better Habitî was strung across Main Street for the duration of the campaign. Businesses and organizations were urged to place these messages on their billboards and flashing signs. The local gas station had the message added to the voice recording that plays continuously as patrons pump gas. Permanent signs stating ìCandor CaresóBuckle Upî were placed at the entrances to the village. Bulletin boards in the schools and local library also addressed the theme.
The nurses from the TCHD and the DSON went to WIC clinics to talk about appropriate car seat use and to do checks for proper installation. This free service was also provided at the Candor Festival of Safety. Nurses from the DSON went to the local preschool to teach the kids how to buckle their seat belts. A song (to the tune of ìWheels on the Busî) was used to reinforce the steps of buckling up. The children also received safety stickers. Literature on air bag safety and proper seat belt and car seat use was provided for each childís parents.
The Candor Festival of Safety was held at Jacksonís Pumpkin Farm on a beautiful fall Saturday. This awareness day was very successful, with an estimated 300 people attending. Emergency vehicles from the local police, fire and EMS departments were there for people to see. In addition an EMS advance life support ambulance from a nearby hospital was there. There were police canine team demonstrations. The state police attended and brought the ìConvincer,î which was used to demonstrate the need for seat belts even in low speed crashes. Vince and Larry were there to greet attendees and give out information on traffic safety. Nurses from the TCHD and the DSON performed car safety seat checks and taught children how to buckle up. Chuckles the Clown attended with her clown carócomplete with seat belt. A regional radio station donated and performed a ìremoteî broadcast for four hours during the event. Many prizes were donated by businesses and given away in frequent drawings at this event. In order to enter the drawing it was necessary to sign a pledge to buckle up. Two regional TV stations as well as the local newspaper provided media coverage.
During the campaign two tragedies occurred that focused attention on seat belt use: The first was an accident that involved a family in the county. There were several fatalities and the media reported that the victims were not wearing seat belts. The second was the death of Princess Diana of England. There was a great deal of media speculation about the role of seat belts in that crash. Its only survivor had been wearing a seat belt. This helped to spur local media interest in the issue and the campaign.
Political Problems, Conflicts, and Resource Constraints
No political problems or conflicts were encountered. One potential conflict concerning resources arose at the community visioning session. A town of Candor citizen asked why the money went to the village of Candor and not the town. The answer was straightforward: The funding agency specified a community with fewer than 2,500 residents (rural guideline), and the village met that criteria whereas the town did not. However, town residents were included in the community visioning session. The community team was well aware of the fiscal restraints prior to initiating the project ($2,000) and worked within that budget, so there were no perceived resource constraints.
Actual Outcomes
The objective of increasing seat belt use in the village of Candor was met! Preprogram seat belt use by drivers was 60 percent and rose to 72 percent postintervention. This was a significant increase using a binomial comparison. Six-month follow-up data was collected in late April and showed that seat belt usage was again declining. It was noted that some areas and times produced higher usage rates than others. For example, the highest percentage of use both pre- and postintervention was on Sunday morning when the count was taken in a church parking lot. One of the lowest counts occurred after school hours at a local roadside eatery and popular teen gathering spot.
Use of seat belts by front-seat passengers preprogram was 54 percent (well below the New York State average of 72 percent), and postprogram it rose to 57 percent. One unexpected outcome noted was the number of car seats that are being used properly. Moms in the WIC Program were using car seats at a high rate. The seats were found to have been properly installed when checks were done at the local WIC site on two different days.
The community was enthusiastic about the project and it was the talk of the village for quite a while. A sign on the Village Office door about a month after the program summed it up nicely. It read: ìCandor Still Cares, Buckle Up.î
Contact: Dr. Pamela Stewart Fahs, Decker School of Nursing, Binghamton, University, Box 6000, Binghamton, NY 13902-6000. Telephone: (607) 777-6805. E-mail: psfahs@binghamton.edu
DISPOSAL PROGRAM |
Mission/Purpose
In the late 1990s Madison County identified as a health threat the issue of home medical waste disposal, specifically, safe disposal of ìsharpsî (syringes, needles, and lancets.) Larry Carpenter, chair of the Madison County Board of Supervisors, and administrators from the Madison County Department of Solid Waste and Sanitation wanted to find a way to insure the safety of the workers at the Alternatives Recycling Center (ARC).
Working with James Zecca, Director of the Department of Solid Waste and Sanitation, and David Dorrance, Director of the Madison County Department of Public Health, Carpenter began looking into ways to insure that workers at the recycling center and private waste haulers throughout Madison County are protected from contact with home medical waste.
Madison County officials reviewed the New York State Department of Health regulations regarding Managing Regulated Medical Wasteómore specifically, Subcategory 4 ó Sharps. According to this information, ìThe single most important aspect of sharps which gives rise to fear and apprehension is their ability to cause puncture wounds and/or lacerations which may cause a portal of entry for infectious agents.î
Officials also looked at programs already in place at the Albany Medical Center and in Ulster County.
Carpenter oversaw the application by Zecca for funds to purchase containers in which private homes could dispose of sharps. The containers were distributed to private homes, at no cost, for use in the disposal of medical waste.
Individuals incarcerated in the county jail were brought into the project to apply informational stickers to the containers to inform private individuals of the proper way to dispose of their syringes. This initiative was instituted prior to the passage of the stateís home medical waste legislation. Madison County was the first county in New York State to have a syringe disposal program. Since the programís inception in May 1991, the county has distributed special disposal containers to the 13 pharmacies in Madison County at no cost.
Special ìSharp!î brochures were designed by the Department of Solid Waste and distributed throughout Madison County, along with numerous news releases and public service announcements describing the new disposal program.
The biggest problem or concern facing Madison County officials was the health and safety of those working at the recycling center and that of private waste haulers throughout the county.
Leadership Role
The sharps disposal program was established through the joint effort of Larry Carpenter, the Madison County Department of Solid Waste and Sanitation, and the Madison County Department of Health. The disposal program, in place since 1991, is monitored by the Department of Solid Waste and Sanitation and the Alternatives Recycling Center.
In June 1996 the program was enhanced with additional disposal sites. The New York State law on syringe disposal went into effect on July 1, 1996. The addition of disposal sites at local hospitals and nursing homes enhanced the countyís existing sharps disposal program.
Key Partners/Stakeholders
The principal partners/lead agencies directly involved in the sharps disposal project are the Madison County Department of Solid Waste and Sanitation, the Alternatives Recycling Center, and the Madison County Department of Health.
Numerous news articles were published in the Syracuse Post Standard, the Herald Journal, the Oneida Daily Dispatch, and all of the weekly newspapers in Madison County, describing the dos and doníts of the sharps disposal program, in addition to public service announcements on local radio station WMCR in Oneida. Brochures are available at all city, town, and village clerkís offices in Madison County and at all libraries, pharmacies, doctorsí offices, hospitals, and the county jail.
Impact/Effectiveness
Out of these collaborative efforts came the process by which medical sharps are collected in the same type of red plastic container used in the health care industry, thereby protecting recycling workers and trash haulers. The county further expanded the initiative by working with the Oneida City Hospital, which assumed the shredding and autoclaving of medical waste, which could then be safely deposited in the countyís landfill. Cost savings were substantial and handling of medical waste became far less of a risk to workers.
Contact: Sharon Driscoll, Recycling Coordinator. Telephone: (315) 361-8446.
Call for a brochure describing the program.
Ulster County Healthy Start is a home-based intervention program designed to prevent child abuse and neglect and to increase parenting skills in at-risk families who reside primarily in Kingston and Ellenville, New York. Operated by the Mid-Hudson Family Health Institute (Institute) under a subcontract with the Ulster County Department of Social Services, it is one of 13 similar programs funded by the New York State Office of Children and Family Services. These programs have been adapted from the national Healthy Families America model, each meeting the distinct needs of the community it serves. One of the unique features of Ulster Countyís program stems from its integration of community health and human services through its operation of a Healthy Families America program within a primary care setting. The result is a model that has united local health and human services in their efforts to achieve seamless, nonduplicative service delivery for families.
Healthy Start is an award-winning, nationally credentialed program. It is a voluntary early intervention program that offers systematic assessment of pregnant women and new parents for risks of child abuse and poor health/developmental outcomes. Families identified with certain risk factors are offered intensive home visitation services until the child is five years old.
The primary goals of the program include:
- promoting positive parenting skills and parent-child interaction, resulting in prevention of child abuse and neglect, reduction in out-of-home placement, and enhanced parent-child relationships
- promoting optimal prenatal care and child health and development, resulting in less need for emergency medical care, early identification and treatment of children with developmental delays, fewer low birth weight babies, and decreased infant mortality
- improving family coping skills and responsibility, resulting in increased self-sufficiency and a reduction in temporary assistance dependency
This program provides a comprehensive primary prevention program for Ulster County that focuses on the safety and protection of children while at the same time preserving and supporting families. The services are easily accessible to isolated at-risk families and are respectful of cultural and community diversity. Healthy Start represents an innovative and comprehensive approach to meeting the health and social needs of pregnant and parenting families.
Organization Description and Program Origin
The Mid-Hudson Family Health Institute is a not-for-profit organization established in 1983 under the licensure of both the New York State Health Department and the New York State Education Department. The Institute provides family practice and some specialty services to about 27,000 persons in primarily rural Ulster County and northern Dutchess County. As an outgrowth of a community movement to address the severe shortage of primary care physicians in the Mid-Hudson region of New York State, the Institute has maintained a dual mission of training and recruiting health manpower as well as developing health care systems to address the needs of the medically under-served. In terms of the former, the Institute sponsors the Mid-Hudson Family Practice Residency Training Program, which has received full accreditation from the Accreditation Council for Graduate Medical Education (ACGME), and also sponsors an American Osteopathic Association (AOA)-approved residency training program. Through its academic affiliations with various medical schools, the Instituteís clinical campus trains approximately 60 medical students per year on family medicine required rotations.
Since its inception, the Institute has been committed to developing integrated systems of health care that not only provide training opportunities for family medicine residents but also address the health care concerns of special-needs populations, using the principles of community-oriented primary care as its guide. Community-oriented primary care is the amalgamation of the principles of community medicine with the clinical practice of medicine. Over the past 16 years, the Institute has sought to study the communityís health needs and to address those needs through community outreach, program development, and resident training experiences that would ameliorate the traditional barriers to comprehensive and continuous primary care for defined at-risk populations.
Formalization of this initiative came through the establishment of the Community Practice Project and Training Program in the early 1980s. The goal is to integrate resident training with community service in order to address the special needs of at-risk populations in Ulster County. Because of the multiplicity of problems that present in the primary care setting when caring for at-risk families, an interdisciplinary team approach to both teaching and family care services was implemented. Each of the teams has a faculty family physician as team leader and has other nonphysician faculty members as appropriate to the teamsí work. Specialty consultants and adjunct faculty from community agencies are also represented on the teams. Currently, there are four Community Practice Teams, which have the responsibility of training family practice residents in the bio-psycho-social approach to the care of at-risk populations and of developing service programs with outreach components and community education projects directed to meet the needs of the targeted groups.
The Instituteís Maternal and Child Health Care Team (MCHC) began in 1983 and was one of the original Community Practice Projectís efforts. At the time, Ulster County had an infant mortality rate in some of its communities that equaled the rates of some of the poorest inner-city communities of New York State. Access to care for the uninsured and Medicaid families was limited, with many high-risk pregnancies receiving late or no prenatal care.
History of Collaboration
The Instituteís MCHC Team, in collaboration with the Ulster County Department of Social Services (UCDSS), implemented several initiatives that led to the inception of the Healthy Start Program. Ulster County DSS and the Institute jointly shared in the cost of hiring a perinatologist from a regional tertiary care center to upgrade the knowledge and skills of local family physicians in caring for at-risk prenatal patients. The perinatologist provided resident and faculty development seminars, patient care consultation, and liaison care between the community and tertiary care setting.
Simultaneously, the Institute, along with UCDSS and members of a local Health Planning Council (Ulster County Sub Area Council of the Hudson Valley Health Systems Agency), conducted a countywide needs assessment based upon risk factors associated with poor perinatal outcomes. From this needs assessment, the Institute applied to the New York State Health Department to become a grantee in a new Prenatal Care Assistance Program (PCAP) initiative. This program was designed to eliminate financial barriers to prenatal care and to incorporate enhanced standards of care to address the multiple medical, social, nutritional, and educational needs of the targeted population. Over the past 15 years, the Instituteís MCHC Team, in partnership with many local and state health and human service agencies, has continued its work and developed a network of primary health care centers in those communities identified as under-served in the original prenatal care needs assessment.
Throughout its existence, the MCHC Team has recognized the need to further develop an integrative system of care and to extend patient care services beyond the ìwalls of medicine,î into the family home and community. In the late 1980s the Ulster County commissioner of Social Services, Thomas Roach, assembled an interagency group of health and social service providers to begin to look at new ways of curbing the rising tide of child abuse and neglect within the county. Considerable work was done in evaluating new strategies whose outcomes were measurable, reliable, and capable of being replicated in a rural setting. The Hawaii Healthy Start Home Visitor model was selected by Mr. Roach and his committee as one that should be adopted in the state; however, the model was modified to emphasize prenatal rather than postnatal enrollment. The commissioner worked diligently with government agencies and elected officials in obtaining funding to establish Home Visitor Programs not only in Ulster County but in nine other high-need areas of the state.
In 1994 the first Home Visitor Programs were established in New York, with the Ulster County program being named Healthy Start. This home visitor model provides intensive parenting and child development education and case management during regular home visits to prenatal and parenting families who have been identified as being at-risk of child abuse and neglect and/or poor birth and developmental outcomes. Ideally, risk assessment by health care providers begins in the prenatal period or by hospital staff at delivery. These individuals then refer their patients/families to the program for a more intensive assessment. If deemed appropriate, the family is offered support services until the child reaches age five. Assuring that all families have a medical home, assisting families in primary prevention and education, and integrating care with other resources available within the community have been the major thrust of this project since its inception. Because of the Instituteís longstanding collaborative working relationship with UCDSS, the county elected to subcontract the operations of the Ulster County Healthy Start Program to the Institute. This decision was also based on the Instituteís philosophy and history of providing integrative health, mental health, and social services to at-risk populations.
Interagency Collaboration and Roles
As the Healthy Start Program entered its implementation stage, collaboration with other health, social, and educational institutions was accelerated. Since its inception, the project has had an interagency advisory board whose role it is to assist the commissioner of Social Services and the Healthy Start Program director in identifying areas for further programmatic development. Its members also serve as liaisons to their respective agencies in addressing systemic issues that present barriers to family care services. The advisory board membership comprises the following medical, early intervention, adult education, and human service communities from the public and private sectors: the Mid-Hudson Family Health Institute; Ulster County Department of Social Services, including representatives from the Early Intervention Program, Coordinated Childrenís Services, and Child Protective Services; Ulster County Department of Health; Ulster County Mental Health; Ulster County Youth Bureau; Preschool Handicapped Childrenís Program; Kingston Hospital; Benedictine Hospital, Ulster County Board of Cooperative Education (BOCES)-FLAG Program; St. Agathaís Prevention Services; the YWCA Teen Parents Program; and the Ulster County Community Action Program-Head Start.
Successful implementation of this primary prevention project required the active participation of the medical community in order to identify at-risk families during the prenatal period. During the first year of operation, the commissioner of Social Services and Institute program staff met collectively with all county providers of prenatal care services and then individually with their office staff in order to facilitate a team approach toward identification of and service delivery to Healthy Start families. In addition, the Healthy Start Program obtained formal affiliation agreements with the two local community hospitals that provide obstetrical services. These agreements outline interagency responsibilities to the overall project and provide a safety net for family referrals should they not be identified through the primary care/prenatal network or by community agencies. These safety net referrals are made by hospital nursing and social work staffs.
The success of these efforts is evidenced by a prenatal enrollment rate of approximately 80 percent of participants in Healthy Start and the fact that approximately 80 percent of its overall referrals come from prenatal care providers. The receipt of these risk screens allows for an assessment worker to contact the family to arrange for an in-home interview, if they are interested. The assessment worker is trained in the administration of the scientifically validated and reliable Kempe Family Stress Checklist. This tool makes it possible to determine whether the family is appropriate for home visiting or is a candidate for less intensive information/referral services.
Other referrals to the program come from governmental and not-for-profit community agencies. About 10 percent are self-referralsóan indication of the positive community perception of Healthy Start.
Another important piece of groundwork for implementing the program involved coordinating with the Ulster County Department of Health. As a result of program outreach and the Mid-Hudson Family Health Instituteís longstanding relationship with the department, the alliance has been a productive one for both parties. Ulster County Public Health Nursing refers to the program, assists with training of workers, and accompanies workers on joint visits when necessary. Healthy Start routinely assures that all appropriate referrals are made to Public Health, especially for the Infant Child Health Assessment Program, by informing them of births to program participants on a monthly basis. Healthy Start also translates for Spanish-speaking Public Health patients when necessary. The programs share the results from their periodic developmental screenings so that when appropriate, the other program does not need to burden families by replicating the activity. As Healthy Start represents a public health initiative, this linkage with the Department of Health has been a critical one.
Other components of the program made possible through the collaborative spirit of the interagency advisory board included obtaining signed agreements with local agencies. First, a memorandum of agreement exists with the YWCA-Teen Parent Program to assure that pregnant teens are accepted into either the Teen Parents Program or Healthy Start, based on which is most appropriate for them and their own preference. This agreement has helped to assure that services are not being duplicated. Second, for two years of program operation, a subcontract agreement existed specifying how the BOCES-FLAG program would help families move toward the performance target of self-sufficiency by offering assistance with literacy, ESL, and the GED process, using original, creative materials that address topics such as parenting and child health. The home visitors worked closely with the FLAG worker to assure that the service plans of both programs were complementary.
Through collaborative efforts, the BOCES-FLAG program coordinator and the Healthy Start Program have established a network of home visitors from a variety of community agencies. For the past three years staff of the Healthy Start Program have met with home visitors from other community-based and governmental programs on a monthly basis for continuing education and networking opportunities. This home visitor network model has been replicated by home visiting programs in Dutchess County and was the topic of a workshop at the National Committee to Prevent Child AbuseóNew Yorkís statewide conference.
From its inception, Healthy Start played an important role in identifying infants and very young children in need of further evaluation for developmental delays. The Ages and Stages Questionnaire, a developmental screening tool, is used every four months and is reviewed by the programís child development specialist, who is a pediatrician with the Institute. After one year of program operation, the Institute signed a contract allowing the home visitors to perform service coordinator duties for families enrolled in the Ulster County Early Intervention Program. This has been quite successful as it decreases the number of workers going into a familyís home, helping to ameliorate some of the anxiety and confusion often felt when families learn that their child has a developmental delay.
Program Operations
The Institute has a multidisciplinary practice philosophy, and Healthy Start program activities and approaches are informed by it. After a family has been screened, assessed, and offered the program, the home visitor addresses the various bio-psycho-social components of the performance targets, utilizing relationship skills, knowledge of the target community (language, health beliefs and practices, attitudes toward discipline and parenting), and prenatal and child development curricula. In conjunction with the home visitor and the supervisor, the family develops an individualized family service plan that includes activities around health, child development, parenting, and self-sufficiency, with specific and measurable outcomes to determine success and those areas in need of continued intervention.
The program provides monthly parenting groups and special events in English and Spanish to help address the social isolation of many of the participants. Presenters are often drawn from the network of health care providers and other agencies.
Letters are sent to the prenatal and child health care providers informing them of the familiesí involvement with Healthy Start. With the patientís consent, providers may share information addressing areas of health, child development, parenting, family functioning, concrete services provided, and crisis intervention. The medical providers have utilized the home visitors to provide health education in a culturally appropriate fashion and to gain a different and often more realistic perception of a family. In addition, many physician residents of the Mid-Hudson Family Health Instituteís residency training program have accompanied home visitors to see participants and observe the work of Healthy Start. This enhances the residentsí understanding of the people for whom they care as well as their knowledge of the work of the home visitor.
In turn, the home visitors appreciate that they are not working in isolation but rather have access to medical expertise and input when required. They have utilized the medical providers for training, general health information, and to assure that they are approaching a certain issue in a complementary fashion.
Program Outcomes
In conjunction with the other NYS Home Visiting Programs, Healthy Start established performance targets to guide and measure its efforts. The following reflect Healthy Start data for the first quarter of the 1998-99 contract year (MarchñJune 1998):
* Includes only families who entered program after 9/1/95.
(Data for this paper obtained from the New York State Home Visiting Program Quarterly Report information through 6/27/98. This data management system has been developed and is maintained by Rockefeller College in Albany, New York.)
As evidenced by these data, Healthy Start has had success in meeting and often exceeding all of its health, child development, child protective, and some of its self-sufficiency performance targets. In coordination with governmental and community agencies, and with the input of its Advisory Board, the program continues to work on strategies for impacting its social supports and self-sufficiency targets.
Obstacles to Program Implementation
A barrier to universal screening has been the perception of some private OB/GYNs that their middle- to high-income patients do not need to be screened for eligibility. During medical provider outreach with the commissioner of DSS and individual meetings, the program director has provided education around the stressors of parenthood that go beyond finances. Over the past three years, most of these providers have begun to universally screen their patients.
An additional obstacle has been that of assuring that the human service community understands the primary prevention nature of Healthy Start. The Child Protective Services unit is often overwhelmed and would like to refer many families whose needs are considered beyond the scope of a primary prevention program. To address this, the Ulster County director of services and the director of the Healthy Start Program collaborated to develop a set of criteria that might make a family already known to CPS eligible for Healthy Start services.
Strengths of Collaboration
The collaboration between the medical and human service community has allowed early identification of pregnant women who are at risk for child abuse and neglect and poor birth and developmental outcomes. Without the prenatal screening implemented by the medical community, the human service community might not have become involved with these at-risk families until they had done something harmful to their children. The Healthy Start advisory board is made up of the medical, early intervention, adult education, and human service communities. Healthy Start benefits from this expertise and can therefore provide for the diverse needs of the whole child and the childís family.
The Healthy Start Program model allows for interventions at the earliest appropriate age levels. The prenatal screening gives medical providers an avenue for referral of their at-risk patients. Home visitors can assist the health care provider in encouraging healthy lifestyles, regular prenatal care, and in the identification of serious social/health risks, such as domestic violence. In addition, as Healthy Start implements developmental screenings every four months, it allows for early identification of delays or warning signs in program children. Due to its close relationship with its families, it has shown success in encouraging participation in early intervention services for families who were previously in denial about their childís condition.
A primary reason for the success of Healthy Start is that services are brought to the familyís home. Since the home visitor is able to see the parent-child interaction as it really occurs, parenting education is informed by these observations. In addition, the home visitor obtains and can share information unavailable to other health or human service providers, which is invaluable for providing appropriate care and services. This information often helps providers to see families in a more positive, realistic light.
An additional strength of integrating services is that when families become involved with various service providers, Healthy Start can coordinate these services with minimal bureaucracy. Due to their involvement on the interagency advisory board, most agencies are familiar with the work and philosophy of Healthy Start. Several of the other NYS Home Visiting Programs have described frustration at their lack of involvement with their local DSS, especially necessary when families do become involved with CPS. Healthy Start has avoided this problem by fostering a good relationship with the various unit directors at the local DSS and through the commissionerís office.
Healthy Start Success
The success of Healthy Start is attributable primarily to the interdisciplinary design of the program, which involved community health and human service leaders. Many programs attempt to address the health and human service needs of families while they are connected only to the health services or to the human services. The result is that parallel systems are created rather than integrative ones. The Mid-Hudson Family Health Institute clearly integrates both of these areas and has demonstrated this in its management of the Healthy Start Program. This collaborative model demonstrates that communities that work well together will have a higher level of success, as evidenced by this programís achievement of performance targets and the coordinated provision of high-quality health and human services to families.
Healthy Start represents an innovative blending of systems and use of resources. As health and human services undergo various transformations, this may be a model that will help to more efficiently utilize resources while improving the health and psychological and emotional well-being of children and families.
Contact: Ellen Butowsky, M.P.H., C.S.W., Program Director, Ulster County Healthy Start, 400 Aaron Court, Kingston, NY 12401. Telephone: (914) 339-8551. E-mail: uchlst@ulster.net
For more information about the Mid-Hudson Family Health Institute, contact:
Sharon Tarolli, C.S.W., Director, Social Work Department. Telephone: (914) 255-2930.
Mission/Purpose
During the fall of 1994, Ulster County District Attorney Michael Kavanagh read an article in the New York Times describing an innovative, award-winning program based in Tulsa, Oklahoma, in which sexual assault victims are treated in a private, exam room by specially trained nurses. These 24-hour, on-call nurses give caring and compassionate treatment to victims while conducting forensic exams to collect valuable evidence. After the exam, victims have access to a private shower facility and a change of clothing in order to feel more presentable and confident prior to being interviewed by law enforcement officials. The program demonstrated drastically reduced response times (from six to eight hours down to 15ñ 20 minutes), and neither victims nor accompanying police officers were required to wait in the public waiting room.
Victims are no longer handled by reluctant medical professionals who are unfamiliar with evidence collection procedures. Nor do they have to leave the hospital dressed only in a gown. This program, called the SANE (Sexual Assault Nurse Examiner) Unit, successfully provides dignity for victims (both male and female, ages 13 and over) while improving procedures for both treatment and prosecution. Although the Countyís Crime Victims Assistance Program has been providing rape crisis intervention and legal advocacy services since 1979, concentrated efforts regarding the medical and forensic components have been lacking. District Attorney Kavanagh, therefore, wanted to create a SANE Program in Ulster County to address these needs in a comprehensive manner.
To assist him with this task, D. A. Kavanagh contacted Donna Fiore, acting director of the Ulster County Crime Victims Assistance Program, who contacted Kathy Bell, director of Tulsa SANE, and obtained the training schedule and related information for program replication. The first priority was to locate compassionate nurses willing to dedicate their time and effort on behalf of victims of sexual assault. Sister Louise Garley, executive director of Benedictine Hospital, was contacted and immediately embraced the program even though funding was unavailable at the time.
Sister Louise approached Emergency Department manager Theresa M. Anderson, R.N., with the proposal, who excitedly agreed to go to Tulsa for training in order to create a SANE Unit for Ulster County at Benedictine Hospital. One of her staff, LuAnn Cook, R.N., enthusiastically agreed to accompany her. Utilizing their own funds, Terry and LuAnn flew to Tulsa and received 40 hours of didactic training and preceptorship. As a result of the training, they were inducted into the International Association of Forensic Nurses. (Terry Anderson, R.N., F.N., was recently awarded the IAFNís Annual Achievement Award for her involvement in creating New York Stateís first SANE Unit. She has also been appointed to IAFNís Committee of Standardization for Forensic Testing.)
Upon their return to Ulster County, Sister Louise arranged for the conversion of an employee lounge into a private exam room with an adjoining shower. Meetings were held with hospital and CVAP staff, the district attorney, the president of the local chapter of NOW, and the director of the local YWCA. Meanwhile, D. A. Kavanagh researched every conceivable funding source, including the Department of Health, the Crime Victims Board, and the Division of Criminal Justice Services. Most said that if they had available funds they would support the creation of the Unit, but none were available. Through the efforts of Senators Charles Cooke and William Larkin Jr., startup funds were made available via legislative member items. Eventually, federal STOP Violence Against Women grants were received.
Leadership Role
District Attorney Kavanagh held a meeting with police chiefs from 17 countywide municipal agencies to introduce the creation of the SANE Program and to explain its nature. These agencies were instructed to have their staff utilize SANE services when situations warranted and to provide victims with transportation to and from the Unit, even if the victim had not yet decided whether to prosecute. Referrals to the SANE Unit come from various agencies, although most originate from police departments. Other sources include ambulance corps, private physicians, schools, the Emergency Department (after assessment), and the victims themselves.
With no permanent funding sources in sight, the Unit became operational on June 1, 1995, and its first exam was conducted on June 4. For the first nine months, Terry and LuAnn provided 24-hour pager and Unit coverage, receiving $150 per exam. (They are donating their on-call assignment fees, for which professional nurses are usually paid at least two dollars per hour, at a total of nearly $18K per year.) Upon receiving a page, they immediately contact the CVAP hotline. Both SANEs and CVAP advocates (staff and/or volunteer) arrive within 20 minutes to provide victim assistance. They have since trained three additional nurses, increasing the SANE staff to its current five.
CVAP advocates tend to the emotional needs of victims. If requested, they remain in the room during the exam, literally holding the victimís hand if need be. Since the victimís clothing is collected as evidence, CVAP coordinates donations of replacement clothing, shoes, and toiletries. If victims choose to prosecute, CVAP advocates also provide moral support during police interviews. They ensure that the nature of the questioning remains appropriate.
After the exam, and with their permission, victims are escorted by advocates to whatever location they request to be transported. Advocates also set up appointments for victims to meet with their staff counselor at the office the following day. Additional needs are determined and resources are provided; hotline calls are responded to and home/hospital visits are made. It is hoped that funding will eventually be obtained for on-site therapeutic services. Although the exam provided by the SANE Unit is free, CVAP advocates assist victims with completing Crime Victims Board Compensation forms and Victim Impact Statements.
Because SANEs volunteer for their assignments and are not appointed, victims no longer have to experience mistreatment at the hands of uncaring or judgmental medical professionals. In addition, Crime Victims Assistance advocates are no longer alone in their mission. Specially trained nurses join them with the same goals in mindóblameless respect and dignity for victims of sexual assault.
To maintain the chain of evidence once a rape kit is opened, attending physicians are not permitted by law to leave the kit unattended. Although nurses had certainly conducted or assisted with rape exams in the past, as SANEs they are now allowed to do so officially and independently. As a result, Emergency Department physicians are now free to completely focus on other life-threatening situations.
Documentation is consistent and thorough, thereby facilitating the prosecutorial process for assistant district attorneys. Victims are further supported by the testimony of SANEs, who are fully committed to testifying to their observations and findings. Juries are becoming more educated as a result of SANE testimony, which is based in both medical and forensic training. It is hoped that such changes will continue to occur throughout the prosecution process. SANE is certainly setting the example.
Since local law enforcement is not centralized, communication with each agency needs to be maintained to track case status. To accomplish this, letters are sent to each court and investigating officers are contacted for updated information. The SANE Program is establishing links that never existed before and is developing good community rapport. The more police officers can be included and involved in the design and implementation of victim assistance programs, the sooner negative practices can be expected to change. As a result, all parties are coming to realize they are on the same team, with similar beliefs and goals: Sexual assault is a crime to be regarded as such, and victims need support after the fact.
Impact/Effectiveness
The program and the victims it serves benefit from the close ties being developed within the criminal justice system and the status gained. Because specific protocol is in place, legal and medical personnel are thoroughly aware and respectful of the otherís duties. Should victims choose to press charges, SANEs temper the situation between victims and police, setting the tone for future interaction. With guidance from the SANEs, police are becoming more comfortable with the very uncomfortable issue of sexual assault. They often express their sincere gratitude for the existence of the SANE Unit.
After three years, the Unit is about to receive its own colposcope with 35mm camera attachment, thanks to another legislative member item submitted by Senator Larkin. In addition, the program is the recipient of the Edward Byrne Memorial Grant ($10,000), which it plans to use in expanding its services to include children.
By the end of 1995, 19 exams were performed by the Ulster County SANE Unit. In 1996, 25 exams were performed; in 1997, 19. The success of the program can be measured by the fact that more than 70 victims have received compassionate and caring treatment otherwise unavailable to them had a SANE Unit not existed. The most notable change is improved relations between law enforcement officials and medical personnel. The program serves as one of the countyís forerunners in demonstrating how a multidisciplinary team approach to handling sexual assault can be very effective. Each agency (medical, advocacy, legal) supports the other toward a common goal.
The success of the program has generated much pressóin particular, a five-page feature article in the December 1996 issue of Redbook. As inquiries arrive from numerous medical and legal professionals (state- and nationwide), tours are conducted and valuable information is distributed to facilitate replication. Each countyís program, however, must develop according to its own resources.
Finally receiving what theyíve been requesting for many years, the public is enjoying a sense of relief and assurance that the systems addressing the needs of sexual assault victims are changing. Professional and faith counselors now have concrete solutions to offer their clients and congregations. Policymakers now know of a very successful option to which they may refer their constituents when presented with the real problem of sexual assault. The healthy community toward which we are striving is the result of concerted action involving multidisciplinary teams of medical, advocacy, therapeutic, and legal professionals. SANE serves as an excellent model for resolving social problems of many types.
Contact: Laurel Herdman, Executive Director, Sexual Assault Nurse Examiner Program (SANE), 275 Wall Street, Kingston, NY 12401. Telephone: (914) 340-3315.
CURRENT CONCEPTS IN WOMEN'S HEALTH: DOMESTIC VIOLENCE AND PRIMARY CARE NEW YORK-BASED |
Mission/Purpose
Domestic violenceóthe presence of coercive or controlling behavior, or intentional violence between people who are or have been involved in family or intimate relationshipsóis a significant threat to the health and well-being of those affected by it. While both men and women can be victims, 95 percent of the victims of domestic violence are women, and some reports suggest that more than 2 million women each year are battered by a current or former partner. In addition to the physical injuries suffered as a result of domestic violence, studies have found links between domestic violence and a range of other medical problems including asthma, headaches, and gastrointestinal disorder and pelvic pain. Thus, domestic violence is both a social problem of enormous consequence and a health care problem whose impact is not sufficiently recognized by physicians.
For 20 years, responding to the needs of victims of domestic violence has been a concern of Victim Services (VS), the nationís largest not-for-profit organization serving the needs of victims of crime. Its collaboration with US Healthcare (now Aetna US Healthcare) to create a tool to educate physicians to identify and intervene in domestic violence has allowed Victim Services to take advantage of the considerable reach of one of the nationís largest health benefits companies.
The product of the collaboration is Current Concepts in Womenís Health: Domestic Violence and Primary Care, a 70-page self-administered Continuing Medical Education (CME) training program for physicians.
Leadership Role
In the early 1990s US Healthcare expressed an interest in being the carrier for VSís health insurance. It was natural for VSís administrators to ask, ìWhat are you doing about domestic violence?î The medical director of US Healthcare countered by asking, ìWhat should we be doing?î Out of that simple exchange has grown a collaboration that joins the nationís largest victim services provider with a leader in managed care to improve the ability of physicians to identify and respond to victims of domestic violence among their patients.
Richard Bernstein, M.D., who is now a senior medical director for Aetna US Healthcare, understood that training physicians to recognize and respond to domestic violence offered US Healthcare an opportunity to fulfill its mandate as a ìprivate public-healthî organization. Physicians are the professionals to whom victims often turn first, and therefore doctors may be able to offer help to victims sooner than social service agencies. In addition, by addressing domestic violence in primary care settings, doctors are able to provide primary preventionówith the hope of reducing the adverse medical consequences of domestic violence.
Dr. Bernstein, along with Michael Kaiser, Victim Services associate director for development and external affairs, played the key role in gathering resources within their organizations to select a way that US Healthcare could respond. Within US Healthcare, Dr. Jay R. Rosan, senior medical director, became a supporter of the project. Victim Services executive director Lucy Friedman also recognized that joining forces with US Healthcare was an unprecedented opportunity. Writers within the agency as well as outside consultants gathered to create a resource that would enable primary care physicians to recognize domestic violence as a medical problem to which they could respond.
Key Partners/Stakeholders
Victim Services is a leader in developing comprehensive services for survivors of domestic violence, helping more than 120,000 abused women each year. Programs include a 24-hour hotline, counseling and shelter for battered women and their children, advocacy in the courts and legal assistance in divorce and custody matters, prevention programs in schools, and an educational program for batterers. In addition, as an employer of more than 600 people throughout New York City, Victim Services is also a purchaser of health care. It was in this capacity that the organization first became aware of the potential for collaboration with its health care provider.
Today, Aetna US Healthcare is the nationís leading health benefits organization, with total health membership of nearly 16 million nationwide. In the New York metro area, the company has more than 1.1 million members and a network of more than 13,000 participating physicians.
Impact/Effectiveness
Aetna USHC has distributed the book Current Concepts in Womenís Health: Domestic Violence and Primary Care to thousands of member physicians. In doing so Aetna USHC made a clear statement that addressing domestic violence among its members falls well within the HMOís mandate as a ìprivate public-healthî organization.
The collaboration has been an especially efficient one, since the CME is a self-administered training and evaluation that physicians can ìattendî at any time. To ensure the continued value of this resource, revisions are made periodically in an effort to keep the statistical and clinical information in the curriculum up to date.
To date, more than 4,000 physicians nationwide have obtained the domestic violence training in the CME. The thousands of participating primary care physicians and Ob/Gyns across the country who have taken and passed the included test not only received required CME credit but also earned increased reimbursement for the care of their Aetna US Healthcare Health Maintenance Organization (HMO) members. Physicians who have completed the course since its introduction in 1995 have responded favorably. However, Aetna USHC officials consider the project a beginning and note that the real measure of success will be a quantifiable reduction in the incidence of domestic violence through earlier detection and prevention. To reach that goal, Aetna US Healthcare has continued to collaborate with Victim Services in addressing the need for research and programs to address the clinical needs of victims of domestic violence.
Contact: Terri Pease, Ph.D., Program Director for the Partnership to Prevent Domestic Violence, 2 Lafayette Street, 3rd Floor, New York, NY 10007. Telephone: (212) 577-1369. Fax: (212) 577-7355.
