In our last post, we discussed the ongoing interest and attention around Social Determinants of Health (SDOH) in primary care, and how telehealth has played an important role during the COVID-19 pandemic in enabling care teams to continue to screen for SDOH and support their patients’ overall health. This week, we will dig deeper into some of the challenges involved with SDOH and provide some suggestions for how telehealth can help address these challenges.
Trauma-Informed Care
Screening for SDOH can involve discussions of sensitive and potentially stigmatizing topics, such as financial and food insecurity, and has the potential to exacerbate or cause new trauma if not done in an empathetic and patient-centered manner.
Trauma-informed care is an approach to working with patients that seeks to acknowledge the whole picture of their situation, circumstances, and history. This approach recognizes the importance of understanding patients’ lives as a whole, that traumatic experiences can have adverse effects on health and well-being, and that providers and care teams may unintentionally retraumatize or disempower patients if they do not adhere to the principles below. While trauma was once considered an atypical experience, research has shown that a majority of Americans have experienced some form of trauma during their lives. The principles of trauma-informed care include attention to each of the following:
- Ensuring physical and psychological safety for patients and staff
- Building and maintaining trust and transparency
- Peer support from individuals with lived and shared experience
- Acknowledging and reducing power differences to foster true collaboration
- Empowering and recognizing strengths and successes, and building resilience
- Recognizing and addressing biases and historical traumas with humility and responsiveness
Applying trauma-informed care principles in clinical settings can be challenging in practice, because it requires not only addressing clinical interactions with the patient, but also rethinking the organizational approach to care. This can be particularly important in telehealth, where clinicians may not be as able to pick up on individual cues or indications of patient discomfort or trauma. Trauma-informed care can help by providing a universal precautions approach that does not rely on disclosure of trauma to initiate a particular protocol or approach to working with a patient. Instead, the principles above help foster a relationship with the patient that promotes trust and healing, centering the patient and their health care priorities.
In this context, telehealth can provide flexibility and access for which the highly prescribed and time-limited nature of in-office visits may not allow. For example, a brief audio-only phone check-in, or asynchronous communication such as texting, may allow patients to fit treatment and care planning into their lives and to build relationships with providers more effectively. It can also help patients feel treated as an equal in managing their own care by letting them engage according to their schedule and preferences. Empowering patients to lead with respect to their own health in collaboration with the routine assistance of a responsive care team is one way telehealth can help improve the patient’s experience, encourage continued engagement, and increase the chance that they will adhere to recommended care.
Intimate Partner Violence
One SDOH topic that can be particularly challenging to engage with patients about is intimate partner violence (IPV). According to Futures Without Violence, the federally-designated National Health Resource Center on Domestic Violence, IPV is defined as one person in a relationship using a pattern of methods and tactics to gain and maintain power and control over the other person. They stress that abusers may not just use physical violence, but also jealousy, mental or financial manipulation, and other tactics to be controlling and abusive. This can make screening for IPV in clinical settings challenging, particularly when a patient is accompanied to their visit by their abuser. As with other SDOH, COVID-19 has exacerbated IPV by forcing more people to stay at home while efforts to address IPV have been complicated and constrained by the pandemic. A dramatic increase in rates of domestic abuse and IPV around the world during the pandemic has highlighted the urgent need for strategies to address the issue.
Patients who are survivors of IPV may have many reasons not to disclose this information when screened, including shame and stigma, fear of threats or reprisal, worry that children might be taken away, language or cultural barriers, and mistrust of providers or institutions. While CDC data indicates that 1 in 4 women and 1 in 10 men experience IPV, responses across the OCHIN network of community health centers showed only 5% to 7% of patients screened disclosed any experience of IPV, which reflects the chronic underreporting of IPV in health care settings nationwide. It follows that there is a need for clinic-based approaches that do not require disclosure as part of the process in order to address IPV.
The CUES intervention was introduced by Futures Without Violence to fill exactly this need. CUES is a trauma-informed and evidence-based universal education and harm reduction approach to addressing sexual violence in health settings. Rather than relying on disclosure of an experience of IPV by patients to initiate an intervention, the CUES approach relies on educating all patients about healthy relationships and offering information and support.
- Confidentiality: Share any reporting requirements your state may have and the limits of confidentiality before talking about patients’ experiences
- Universal Education and Empowerment: Offer all patients two safety cards with information about relationships and health – one for them and one for a friend or family member
- Support: Disclosure is not the goal, but be ready if it does happen. Make a warm referral to a partner domestic/sexual violence agency or to a national hotline
Adapting this approach to telehealth can still be accomplished in a trauma-informed and patient-centered way. Disclosure is still not necessary or required for the intervention, but ensuring privacy is a priority – and it can be a challenge. This JAMA Insights article by Melissa Simon, MD, MPH, advises to start any telehealth screening for IPV with simple yes/no questions to determine if it is safe for the patient to answer further questions about IPV.
If another person is present, the article suggests that the provider should state, “HIPAA laws require that I conduct the telehealth visit with no one else present.” Once the person is alone, asking only yes/no questions can avoid inviting open ended responses that the patient may not be comfortable or safe providing. Dr. Simon suggests letting the patient know that these are questions you ask of all patients, and even starting off with COVID symptoms or other questions before moving on. Questions like “Are you feeling stressed?” or “Do you feel safe at home?” are appropriate initial questions.
For some patients experiencing IPV, shelter-in-place and other pandemic restrictions may compound intentional isolation by abusive partners, meaning telehealth visits with healthcare providers may be one of the few times they are able to connect with people outside their household. This can be especially true for patients who primarily speak a non-English language, so using professional telephone interpreters, rather than relying on the patients’ family or friends, is important for ensuring confidentiality.
Finally, instead of providing physical safety cards, telehealth providers should consider sending safety information electronically through email, text, or other means; although this must be weighed against the risk of interception or even impersonation by abusive partners. Including accompanying text such as, “Here is some information we share with all patients,” and/or encouraging them to share it with anyone they know who might benefit can help offset this risk.
We hope this information has helped you understand some of the challenges that trauma-informed approaches to care can help address, how telehealth can be an important part of these strategies, and specific ways you can modify your approach when working with a trauma-informed intervention via telehealth. If you have questions about this post or would like to learn more about our services, please contact the California Telehealth Resource Center (CTRC). [Link]
If you, or someone you know, is in need of assistance:
- The National Domestic Violence Hotline is confidential, open 24/7, and has staff who are kind and can help you with a plan to be safer: 1-800-799-SAFE (1-800-799-7233) / TTY 1-800-787-3224 thehotline.org
- Text trained counselors about anything that’s on your mind: Crisis Text Line crisistextline.org Text “START” to 741741
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