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Current Level of Care

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Origin SC is a nonprofit located in North Charleston, South Carolina. Primarily focused on improving the quality of life for individuals in the Charleston Tri-County area through financial independence. With numerous accreditations, Origin SC offers a variety of services including: financial education and coaching, housing stability through its conservatorship and representative payee department, and One Less Homeless Vet program. In addition to these services Origin SC has a family violence intervention department. Through this department, batterers interventions, domestic violence victims programs, and anger management programs are offered.

The family violence intervention department serves a very diverse population made up of many ages, races, and socioeconomic statuses. The department receives the majority of its clients from referrals given by external agencies like the South Carolina Department of Social Services and the Solicitors Office; although, some clients are self-referred. The family violence intervention department is made up of a Licensed Independent Social Worker (LISW), an Outreach Navigator/ Court Advocate, two Case Managers, and 2-4 Master of Social Work Interns. There is some level of integrated care within the organization as individuals that complete the Domestic Violence Victim’s Empowerment program, are able to utilize all of the financial education and credit counseling courses free of charge. Additionally, although Origin SC is oftentimes a referral made to clients from an external agency, there are few collaborative linkages to other outside resources. The most frequent referral source that Origin SC currently utilizes is My Sister’s House, the only domestic violence shelter located in the Tri-County area.

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The Importance of Integrated Care

Integrated care is important when working with survivors of domestic violence (DV). The 2010 National Intimate Partner and Sexual Violence survey found that some of the top needs reported by survivors of DV include access to medical services, court advocacy, and behavioral health services. However, what is more alarming is that more than half of the same women surveyed, stated that they were unable to access any of these resources (Breiding, Chen & Black, 2014). One study reported that victims of domestic violence utilize healthcare services more frequently when compared to women that have not experienced domestic violence (Rivara et. al, 2007). The same study also found that even when the domestic violence victim was post-five years from experiencing abuse, their utilization of healthcare services was still 20% higher when compared to women that had not experienced domestic violence (Rivara et. al, 2007). This finding shows that the experience of domestic violence often has lasting physical and emotional effects, even after the abuse has stopped taking place.

Most recently, the U.S. Preventive Services Task Force and the Department of Health and Human Services recommended that healthcare providers be trained in crisis management, implement comfort measures, and provide referrals to community resources (Hamberger, Rhodes & Brown, 2015). While these recommendations are excellent starting points, the effectiveness of relying solely on emergency departments to identify victims of domestic violence, in order to provide them with appropriate referral sources, is debatable as numerous studies have examined the effectiveness of this method. Two researchers found in their study of 964 victims of domestic violence, as identified by a prosecutor’s database, that 788 (81.7%) of the victims had visited the emergency room at least once during the 3-year study. During that time there were 4,456 total visits made to the ER, but only 1,349 of the visits resulted in a screening for intimate partner violence. Of the “1,349 (30.3%) of the 4,456 total visits, only 259 (5.8%) resulted in positive screens” (Kothari & Rhodes, 2006). These findings reveal that while hospitals are attempting to identify incidences of domestic violence, it is not enough to rely on them to connect the victims with the appropriate social supports and mental health services.

Another study found that by incorporating a chronic- care model in addressing domestic violence, many of the barriers to treatment that were stated by victims were eliminated or significantly reduced. The stated barriers included: the client’s access to the knowledge of organizations, time, and a lack of positive rapport with service providers (Waalen et al., 2000). The 2013 Intimate Partner Violence Screening and Counseling Research Symposium stated that their vision was for “intimate partner violence screening and intervention in clinical settings to include three key components: screening and assessment; intervention, referral, and follow-up” (Ghandour, Campbell, & Lloyd, 2015).

As Origin SC is a supportive agency it would be part of the follow up. As an agency, it currently receives referrals and conducts assessments to determine whether or not the client should be recommended for services. If recommended, the client then receives an intervention in the form of psycho-education. Though there is a referral list of counseling, mental health, and crisis services made available to clients if desired, there is currently no formal screening performed to determine if additional mental health services may be needed once the program has been completed.

Desired Level of Integration/Collaboration

Origin SC acts at the second level of collaboration and integration. As the department currently acts as a referral source for many external agencies dealing with individuals affected by domestic violence, their systems are typically separate from the external agencies. Communication between external agencies is frequent, but usually on an as needed basis for clients that are under pre-trial interventions or mandated by the state to attend as part of their treatment plan. The family violence intervention program at Origin SC has a very specific set of responsibilities in regard to the care of a client, as they primarily provide recommendations for psycho-education services, court advocacy, and psycho-educational group sessions. Outside of these two specific clinical deliveries, they are not responsible for providing any additional services. The treatment plan designated by Origin, for clients that have been recommended for services, is the successful completion of 16-28-week group sessions. In many cases the treatment plan created by external agencies involves additional steps outside of completion of the program.

Structure for Integrated/ Collaborative Care

As the family violence intervention department is within the agency of Origin SC—it would not be feasible to move the entire department in order to be in close proximity to collaborating agencies. While this is currently not a feasible solution, in the past there have been attempts made in transitioning the family violence intervention department in having a physical presence at the All Of Us Resource Day Center, which was aimed at serving the LGBTQIA+ homeless community. Unfortunately, this resource day center has since closed and will not be reopening until further notice.

As a second level integrative and collaborative care organization, there are some objectives that could improve the current delivery of services. Connecting clients with mental health resources post- completion of the psycho-education program, if symptoms of mental illness remain present and problematic, is the goal of this proposed policy. Though the psychological health of clients at Origin SC is not a designated responsibility of the care given through the offered services- by assessing clients for the presence of common mental health disorders seen in victims of domestic violence, the problem(s) can be addressed through referrals to other agencies, of which treatment of these issues are within their scope of practice. Eliminating various barriers that may have kept clients from seeking treatment, resulting in the client receiving his needed services.

Many studies report that victims of domestic violence commonly experience depression, post-traumatic stress disorder (PTSD), and anxiety. One specific study found that the severity and extent of the abuse also often increased the severity of the mental health symptoms reported by the victim (Lagdon, Armour, & Stringer, 2014). Additionally, the 2010 National Intimate Partner and Sexual Violence Survey reported that 22.3% of the female survey participants reported 1 or more symptoms of PTSD (Breiding, Chen, & Black, 2014). Another study with 680 female victims of domestic violence stated that 45.3% of the women reported clinical symptoms of depression and 30% reported experiencing suicidal ideation over a span of time greater than 4 weeks (Gibbs, Dunkle, & Jewkes, 2018). As mentioned, anxiety is also a common occurrence when working with victims of domestic violence. According to the National Center on Domestic Violence, Trauma and Mental Health, domestic violence survivors are at three times the risk of being diagnosed with an anxiety disorder, when compared to individuals that have never experienced domestic violence (2014).

Many times, the presence of PTSD and depression symptoms are seen in domestic violence victims. Researchers in one study reported that 45% of their study sample experienced the co-morbid symptoms of PTSD and depression. This same sample size also had “57.4% of the overall sample meet criteria for PTSD, while 56.4% met criteria for depression” (Nathanson, Shorey, Tirone, & Rhatigan, 2012). In general, when analyzing studies research shows that “PTSD is experienced by 51% to 75% of women who are victims…. and depression has been diagnosed in 35% to 70% of women that have been victimized” (Nathanson, Shorey, Tirone, & Rhatigan, 2012).

Research has shown that survivors of domestic violence often show increased rates of depression, anxiety, and PTSD. These elevated rates sometimes exist for up to five years after the abused has ceased (Hamberger, Rhodes, & Brown, 2015). As Origin SC’s current domestic violence victim psycho-education course is only 16 weeks long, it would be naive to assume that all pre-existing mental health issues are completely addressed throughout the 16-week program. While Origin SC does have a Licensed Independent Social Worker (LISW) on staff, individualized counseling is not a service that is specifically offered to all clients. Therefore, one way to address the potential mental health issue would be to screen clients for symptoms of PTSD, depression, and anxiety during their admission to the program, mid-completion, and exit interview. By tracking the presence of these symptoms, facilitators will be able to see if the psychoeducation sessions are having any affect in reducing the symptoms that these clients may be facing. Additionally, group facilitators or the LISW would be able to inform the client that they are experiencing symptoms of the following mental health disorder(s) and provide them with a list of possible behavioral health service providers that are both financially and physically accessible to the client.

This policy would require group facilitators, MSW interns, and exit interview facilitators to utilize Beck’s Depression Inventory, PTSD Checklist for DSM-5 (PCL-5), and Generalized Anxiety Disorder-7 (GAD). All of these measurement tools are short scales that can be done within 5-10 minutes. Which can be given at the beginning of the session so that facilitators are able to gather the needed information from all program participants. Beck’s Depression Inventory has been deemed a reliable tool when assessing an individual for the symptoms of depression. One study that focused on the psychometric properties of the Beck Depression Inventory, reported that their meta-analysis found that this scale had a “coefficient alpha of 0.86 for psychiatric patients and a 0.81 for non- psychiatric patients” when focusing on the internal consistency of the scale (Beck, Steer, & Carbin, 1988). According to the U.S. Department of Veterans Affairs, “The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). But when necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis” (U.S. Department of Veterans Affairs, 2017). A study featured in the Journal of the American Medical Association found that the internal consistency of the GAD-7 had a Cronbach’s alpha of 0.92 and in regard to the “test-retest reliability the intraclass correlation was 0.83” in its measurement of anxiety symptomology (Spitzer, Kroenke, Williams, & Löwe, 2006).

Plan for Monitoring Implementation and Assessment of Services

In order to carry out this policy, administers of these scales need to be educated on how the scale is scored and what each score means. A staff member, possibly an intern, could be responsible in the scoring of each participants’ answers. In addition to obtaining the scales needed, a list of behavioral health centers would need to be created so that the referrals are readily available to be given to the prospective client. The implementation of this proposal would be monitored by the family violence intervention staff, primarily by the individuals that co-facilitate the domestic violence victims support group. Assessing the success of this proposal would be done through communication between Origin and the outside local mental health agencies where symptomatic clients would be referred. As per the integrated care policy, Origin and the mental health agencies clients would be referred to would communicate with each other to ensure clients have sought the care that was recommended for them.

Support and Funders

Possible supporters of this proposal include the Chief Executive Officer and Chief Financial Officer of Origin SC. As the mission and vision of Origin SC is to empower individuals, families, and the community to achieve stability, by assisting clients served through the family violence intervention department, in receiving access to mental health services when needed; this goal of stability is enhanced through the implementation of this policy. Other potential supporters of this policy proposal would be local mental health agencies, who would benefit from the client referrals they would receive as a result of this policy, hospitals and urgent care facilities, which would benefit by reducing the amount of ER and urgent care visit by DV victims, and community residence, who would also benefit from a decrease in ER and urgent care use by DV victims, as wait times would then be shorter. Domestic violence advocacy groups like the South Carolina Coalition Against Domestic Violence and Sexual Assault and Thrive SC, a transitional housing and holistic DV service non-profit, would also most likely support the proposal as it’s sole purpose is to encourage continuation of care, if needed, and improve quality of life for those clients still struggling from DV after program completion. An additional supporter of this policy would be the South Carolina Department of Social Services. As many of the clients that are seen at Origin SC have been referred by this external agency and often involve children. One study reported that parents experiencing mental illness create an atmosphere of toxic stress for their child causing elevated stress levels, which negatively affect their neurological development. Leading to probable developmental and behavioral impairments later in life (Gupta & Ford-Jones, 2014). The implementation of this policy and its ability to connect “at risk” adult clients with mental health resources, would not only improve the quality of the client’s life, but also that of their children. Furthermore, DV victims would also strongly support this policy proposal as it provides them with the resources and information needed to continue their journey of an improved quality of life.

In addition to improving quality of life for clients, this policy is one that comes at a low cost, and can be easily implemented into the current processes and procedures that take place within the department. The cost effectiveness and ease of implementation with this policy may also encourage the support of the head of the family violence intervention division, as she is also a social worker. The only resources needed for the implementation of this policy would be printer paper, ink, an individual to grade the scales, and the time of a staff member to research local community behavioral health services available to the clients that are deemed at risk.

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