Need: To address intimate partner violence (IPV) in primary care settings as a health concern. To increase healthcare providers' professional understanding about its prevalence and adverse impacts on patient health.
Intervention: In partnership with Safer Futures, Tides of Change provides an advocate at a local health clinic to give confidential services to IPV survivors and training to medical staff. The advocate uses curriculum and other materials designed by Futures Without Violence.
Results: Healthcare providers at the clinic reported increased understanding of IPV and its impact on health. As a result, IPV advocates received an increase in referrals from healthcare providers. Patients experiencing IPV reported a reduction in chronic, toxic stress and improved overall health after receiving advocacy services.
Without Violence (FUTURES) is a national nonprofit
working to prevent and end gender-based violence that
disproportionately impacts women and children. As part of
Improving Health Outcomes Through Violence Prevention
Pilot Project, FUTURES selected 10 domestic violence
programs and community health centers across the U.S. to
receive financial assistance, training, and support.
During a 10-month period, these pairings partnered to
promote the increased safety and improved health outcomes
of those experiencing IPV.
One such partnership is Oregon's Tides of Change (a
member of the Oregon
Coalition Against Domestic and Sexual Violence that
serves current and past survivors of domestic violence,
dating violence, sexual assault, stalking and
trafficking), and the Rinehart Clinic &
Pharmacy (a Federally Qualified Health Center). Tides
of Change is a nonprofit IPV assistance center that also
provides an advocate stationed at Rinehart Clinic one day
a week. The advocate accepts referrals from healthcare
providers and consults with providers on warning signs of
IPV that arise during patient exams. When the advocate is
not present, the clinic's social workers step in to
assist providers in addressing the patient's needs.
FUTURES screening and intervention tools were first used
in Tillamook County as an
initiative of the Oregon Department of Justice Safer
Futures project – a statewide project that offers IPV
advocacy and support in child welfare offices, public
health departments, and local primary care clinics. The
Safer Futures project operated between August 2013 and
July 2017. Support was provided by the Pregnancy
Assistance Fund through the Federal Office of Adolescent
Confidentiality – Disclosing the
limits of confidentiality before discussing IPV with
Universal education – The use of
cards to help patients differentiate between
healthy and unhealthy relationships
Empowerment – Giving each patient two
cards, so they can help a friend or family member
Support – Leaving the patient with
referral numbers on the cards and making a warm
referral to an advocate when appropriate
The advocate offers free and confidential support
services to patients experiencing IPV, including ongoing
assessment and safety planning, systems navigation, and
connecting them to community and legal resources as
When the advocate is not onsite,
the advocacy program staff is available to take referrals
over the phone.
Tools, Resources, and Assistance
FUTURES provided the following support to the
Quality improvement tools to assess IPV
Resources to facilitate a productive partnership
Capacity building support designed to sustain the
project beyond grant funding
Regular leadership team meetings
with all 10 participating partnerships
Safer Futures conducted a focus group comprised of
Rinehart Clinic's healthcare providers to evaluate the
effectiveness of the FUTURES intervention. Providers
reported an improved understanding of IPV and its impact
on health. They also gained more confidence in talking
about IPV with patients and making referrals to IPV
The clinic now universally screens every patient at the
start of the appointment. A change they implemented was
"solo patient rooming," allowing for patients to have the
privacy to disclose information about their relationship
Because of the risk of disclosure to the partner causing
harm, Rinehart Clinic medical staff have taken extra
precaution in documenting in a patient's electronic
medical record regarding IPV. After a referral is made,
documentation occurs in the advocacy group's record
Safer Futures also conducted survivor interviews to gauge
the impact of healthcare referrals to advocates. The
interviews revealed the following results for patients:
Reduction in chronic, toxic stress
Reduced fears of reaching out
Additional data from the broader Safer Futures cohort of
healthcare projects (August 2013 to September 2017):
Advocates served 955 pregnant women and mothers.
Women 20-24 years old represented the largest age
100% of women agreed that by working with an
advocate, they can make informed choices about their
97% of women agreed that by working with an advocate,
they have new ideas for how to stay safe.
100% of women agreed that by working with an
advocate, they know more about resources available to
Nearly 500 referrals from healthcare professionals
were made to Safer Futures advocates.
Safer Futures provided 119
trainings to 1,575 Oregon healthcare professionals.
Having an advocate located at the Rinehart Clinic has
given providers and patients direct access to IPV
assistance. This has helped providers grow in their
confidence to address IPV as a health concern and has
continually provided them with a resource to increase
their understanding of IPV and how it impacts their
The on-site advocate also helps break down psychosocial
barriers preventing a patient from taking action.
Providing assistance in the local setting cuts down on
travel time and cost for patients who would otherwise
have to travel up to an hour to receive assistance.
Before the start of the project, there was a general
lack of understanding about the breadth and depth of IPV
in Tillamook County and in the hospital. Many healthcare
providers did not understand the role of an IPV advocate
as complimentary and distinct from that of licensed
clinical social workers. Tides of Change educated
healthcare providers about the differences.
Many patients who experience IPV don't self-identify
as survivors or are fearful of potential repercussions of
disclosing their situation. Few patients disclose IPV
during an exam unless directly asked. Providers have
limited time and much to cover during an exam and can
easily miss opportunities to identify signs of IPV or
related health factors.
Tides of Change staff initially helped the clinic
remove barriers involved with screening in addition to
educating medical staff on the risks those who experience
IPV encounter when trying to leave. Provider conversation
scripts around disclosure and mandatory reporting were
Confidentiality is required for any interaction
between an advocate and a patient. Advocates do not
notify providers if a patient engages in advocacy
services or intervention steps. Providers are encouraged
to speak directly with their patients about IPV and the
services available to them.
Nonprofit health insurance companies are looking at
community solutions to improve healthcare services and
reduce cost of IPV for local hospitals and clinics. The
Centers for Medicare & Medicaid Services does not
reimburse for services provided during appointments with
IPV advocates. The most common sources of funding for
advocacy and healthcare partnerships in Oregon is grant
and foundation funding and charitable contributions.
Because the clinic advocate is dependent upon
non-clinic funding sources, if absent for extended
periods of time, referral numbers decline.
The shift in mindset of medical
staff (including providers and medical assistants) toward
quality improvement was a challenge. Implementing a
screening process required a staff workflow shift, which
was guided by a quality improvement process such as
toolkit recommends healthcare facilities take the
following steps to secure a successful program:
Build partnerships between healthcare
settings and local, community-based IPV organizations.
Implement an IPV policy that addresses
the identification of and response to IPV during exams,
promoting prevention, and connecting survivors to IPV
Educate all patients and staff about
the connection between IPV and their health and engage
them in strategies to promote wellness and safety.
Evaluate your progress on a regular
FUTURES tools used by Tides of Change and the Rinehart
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.