SAN FRANCISCO (WOMENSENEWS)--Cassandra Floyd seemed to have it all.
An accomplished OB/Gyn at a Kaiser Permanente hospital in San Jose, Calif., she had a beautiful daughter and had graduated with honors from the University of California at Berkeley and University of California San Francisco School of Medicine.
But in November 2001--in an event that shocked everyone in her life--her ex-husband, who worked in advertising sales at a radio station, shot and killed her while their 4-year-old daughter slept nearby. He later shot himself.
Floyd's death, advocates say, is a stark reminder of the hidden nature of domestic violence--even for those working in the health care system with access to help.
Thirty-seven percent of women who sought treatment in emergency rooms for violence-related injuries in 1994 were injured by a current or former spouse or romantic companion, according to the Family Violence Prevention Fund.
The U.S. health care system spends $4.1 billion on direct medical and mental health services for patients experiencing domestic violence, according to a 2000 study in the Archives of Family Medicine.
Floyd's former employer, Oakland-based Kaiser Permanente, a national health maintenance organization, is bringing the problem out of the shadows through a unique comprehensive program for patients and staff.
Kaiser Permanente Northern California launched the pilot program in 1998. Since it rolled out to all 35 medical centers in the region by 2000, findings of domestic violence has increased three-fold among patients.
The nationally recognized program is unique because it takes domestic violence screening beyond the emergency room and connects those experiencing violence in the home with a network of resources quickly, both within the health care setting and in the community.
The program has won numerous awards, including from domestic violence groups and the American Association of Health Plans, a national association of health insurance plans.
Plans are underway to expand the program across the country.
Jump in Domestic Violence Diagnoses
Through the program, more and more patients are being screened in the exam room as opposed to the emergency room. In 2000, 110 patients were diagnosed with domestic violence in a primary care setting only (OB/Gyn, medicine and family practice). In 2003, that number grew to 883. A total of 761 patients were diagnosed with domestic violence at Kaiser facilities in 2000. In 2003, the figure jumped to 2,575.
"We're identifying the situation before people come in with a broken bone or a black eye," said Dr. Brigid McCaw, clinical lead for Family Violence Prevention Program at Kaiser Permanente Northern California.
A key component is training clinicians to ask their patients about home life during routine exams. An innocuous question like "How are things at home?" can lead to an open discussion.
Chest Pain, Heart Palpitations
McCaw remembers seeing a female patient in urgent care who was complaining of chest pain and heart palpitations.
"She was a young healthy woman who didn't seem to have risk factors for heart problems. I asked her how things were at home and she said, 'The kids don't like that my husband and I fight.'"
The patient said her husband called her names like "pig" and "shit" and encouraged the children to call their mother these names too.
"He hadn't threatened her or hurt her but he had threatened suicide if she left him," McCaw said.
The woman participated in Kaiser's group therapy program for intimate partner violence. "She started thinking about these issues," McCaw said.
People in abusive relationships often show physical symptoms from the stress, including headaches, anxiety, depression and chronic abdominal pain. Other symptoms of domestic violence are not getting the kids vaccinated on time or missing appointments. Abused women have a 60 percent higher rate of neurological, gynecological and stress-related problems compared to women who have never been abused, according to Kaiser Permanente.
"What Brigid gets is that it's all connected," said Rebecca Whiteman, a senior health analyst for the Family Violence Prevention Fund in San Francisco. "The great thing about Kaiser is that they are looking at the broad spectrum of patients, not just the pregnant women or the teen girls. They're where we wish most people were."
Congress Considers Domestic Violence Screening
Congress is now considering enhancing domestic violence screening in health care centers as part of the Violence Against Women Act of 2005. That law, known as VAWA 2, would reauthorize the landmark anti-gender-violence act that provides funding for civil and criminal justice response to gender-based violence. The bipartisan bill was introduced in the Senate last week and will be introduced in the House today.
VAWA 2 includes funding for training and education of health professionals to screen for domestic violence in their patients. It would also fund partnerships between health care providers and community groups, such as shelters and rape crisis centers.
An estimated 5 percent to 14 percent of U.S. women are living in abusive situations, and 1-in-3 are assaulted by a domestic partner sometime in their lifetime, according to the Family Violence Prevention Fund.
"We have a culture of not inquiring about partner violence," McCaw said. "The shame and stigma makes people not be open about it. It takes someone asking about it in a caring way."
It also takes a network of services that people in abusive situations can access readily, McCaw said. Kaiser is at an advantage over most health services because it is a health plan, medical center, pharmacy and outpatient clinic in one.
Patients don't need to wait to obtain insurance approval for a visit with a mental health counselor, for instance. In addition, Kaiser has formed partnerships with community domestic violence groups and also refers patients to shelters and food banks.
Identifying Problems Among Employees
Other health plans such as Blue Shield of California and Health Insurance Plan of Greater New York have also taken a lead in addressing intimate partner violence. Blue Shield holds trainings for employers in California to identify and help with a domestic violence situation. It also offers educational sessions for employees. Liz Claiborne Inc. pioneered domestic violence training in the workplace and now offers the training to the public and to other companies.
Meanwhile, Kaiser is working with its human resource departments to better identify intimate partner violence among its employees.
A traveling exhibit called "Silent Witness" highlights the stories of Kaiser Permanente employees who are survivors of domestic violence. The display--featuring words written on a stark black background--is circulating at Kaiser facilities and at Macy's department stores in Northern California.
One woman who shared her story in the exhibit wrote that few knew the truth about her marriage. "Firearms were involved and I feared for my life," she wrote. "I became very ill during my marriage with chronic insomnia, night sweats, arrhythmia and I developed positive markers for lupus."
Her physician asked how things were at home, and said "I'm concerned about you, I'm afraid if your husband doesn't kill you, the stress will."
"I didn't leave my husband that day but the physician's words were part of what it took for me to finally leave," the woman wrote. "My health is completely back to normal."
The woman who shared her story is a 42-year-old Kaiser psychologist.
"The project shows strength," McCaw says. "These are people in disturbing relationships but they do get help."
Rebecca Vesely is a health care reporter at the Oakland Tribune.
For more information:
Northern California Family Violence Prevention Program:
Family Violence Prevention Program:Another Way to Save a Life
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