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2023 HSR&D/QUERI National Conference Abstract

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1164 — A Stepped Wedge Hybrid-II Trial to Implement Intimate Partner Violence Screening Programs in VHA Primary Care Clinics

Lead/Presenter: Katherine Iverson,  Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System
All Authors: Iverson KM (Center for Healthcare Organization and Implementation Research (CHOIR), Boston, and the National Center for PTSD, VA Boston Healthcare System), Stolzmann, K (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Brady, JE (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Adjognon, OL (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Dichter, ME (Center for Health Equity Research and Promotion, Philadelphia) Portnoy, GA (PRIME, VA Connecticut Healthcare System, Yale University School of Medicine) Gerber, MR (Albany Medical College) Iqbal, S (VA Palo Alto Healthcare System) Haskell, SG (Office of Women's Health Services, Yale University School of Medicine) Bruce, L (VHA IPV Assistance Program, Care Management and Social Work Services) Miller, CJ (Center for Healthcare Organization and Implementation Research (CHOIR) Boston)

Objectives:
Intimate partner violence (IPV) is a population health problem that disproportionately impacts women veterans. The Veterans Health Administration (VHA) recommends evidence-based IPV screening in primary care to identify women who may benefit from support services. But the uptake of IPV screening programs is slow and incomplete in mixed gender (model 1) and shared-space (model 2) women’s health primary care clinics, where the majority of women VHA primary care patients seek care. We partnered with VHA’s Office of Women’s Health Services (OWHS) and the IPV Assistance Program (IPVAP) to conduct a randomized program evaluation trial evaluating implementation facilitation (IF) to enhance the uptake of IPV screening programs in mixed-gender and shared-space primary care clinics. This investigation examines IF’s impact on implementation (i.e., reach of IPV screening) and clinical effectiveness (i.e., disclosure rates and post-screening psychosocial service use) outcomes.

Methods:
A cluster randomized, stepped wedge, hybrid-II design compared IF to implementation as usual within VHA. IF was led by OWHS and occurred in two waves across nine sites. IF consisted of an external facilitator from OWHS working with a facility-funded internal facilitator from within participating primary care clinics (e.g., physician or nurse) working with a designated PACT team and the site’s IPVAP Coordinator for six months. Using RE-AIM as an analytic framework we examined medical records to identify changes in reach (i.e., IPV screening rates) and effectiveness (i.e., disclosure rates and post-screening psychosocial service use [e.g., mental health and social visits]) associated with IF. All women receiving care at participating clinics in the 3 months prior to IF (pre-IF period; n = 2272) and 9 months following the start of IF (IF period; n = 5149) were included in analyses. We estimated outcomes using chi-square tests and generalized estimating equations (GEE) with site as a random effect.

Results:
In terms of reach, women seen during the IF period were nearly 3 times more likely to be screened for IPV compared to the pre-IF period (OR = 2.70; p < .0001). Regarding disclosure, among all screened women, those screened during the IF period were not more likely to disclose IPV compared to those screened during the pre-IF period (OR = 1.14; p = .36). However, among all eligible women, those seen during the IF period were more likely to disclose IPV compared to those seen in the pre-IF period (OR = 2.1; p < .0001). Additionally, among all screened women, those screened during the IF period were more likely to receive psychosocial services within 60 days post-screen than the pre-IF screened women, adjusting for pre-screening psychosocial service use (OR = 1.29; p = .01).

Implications:
Operations-led IF increased the reach of IPV screening programs in VHA primary care clinics, thereby increasing detection of IPV among the patient population and strengthening connections to potentially life-saving VHA support services.

Impacts:
Findings inform VA OWHS and IPVAP scale-up efforts. Facilitating IPV screening program implementation can ensure the translation of policy into clinical practice in VHA, thereby improving Veteran outcomes.