Women’s Health In The 86th Texas Lege Add AAFP Virtual Care To Your Practice Will There Be An Alternative To The Board Exam Soon?
TEXAS FAMILY PHYSICIAN VOL. 69 NO. 4 2018
INTIMATE PARTNER VIOLENCE An Epidemic Family Physicians Can Address
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TEXAS FAMILY PHYSICIAN VOL. 69 NO. 4 2018
6 FROM YOUR PRESIDENT “Apollo 13” and behavioral health
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8 NEWS BRIEF ABFM to pilot alternative to board exam
Intimate partner violence: A hidden epidemic
When you know your patient isn’t safe at home, you know you need to act. Experts from the Texas Advocacy Project explain what you should do and what Texas law says you must do to help your patients in violent relationships. By Kelly Thorstad, MD, Heather Bellino, and Cynthia Y. Herrera, JD
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Advocating for patients in the #MeToo era
How do you recognize the signs of sexual violence when you’re in the clinic? A New York family physician writes about her experience building a clinic for people who have experienced sexual trauma. By Anita Ravi, MD, MPH, MSHP
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What’s on the agenda for women’s health?
With mere weeks left before the start of the 86th Texas Legislature, the Texas Women’s Healthcare Coalition prepares its priorities to improve access to care for women across the state. By Evelyn Delgado
10 MEMBER NEWS Fields wins AAFP executive award | Ferrer elected to National Academy of Medicine | Chassay named distinguished alumnus by McGovern Medical School 12 PRACTICE MANAGEMENT Your Academy offers new telemedicine platform 30 PERSPECTIVE Asking the “One Key Question”
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PRESIDENT’S COLUMN
TEXAS FAMILY PHYSICIAN VOL. 69 NO. 4 2018 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.
Our next moonshot – fixing the state of behavioral health in Texas By Janet Hurley, MD TAFP President
OFFICERS president
Janet Hurley, MD
president-elect vice president treasurer
Rebecca Hart, MD
Amer Shakil, MD, MBA
Javier “Jake” Margo, Jr., MD
parliamentarian
Mary Nguyen, MD
immediate past president
Tricia Elliott, MD
EDITORIAL STAFF managing editor
Jonathan L. Nelson
associate editors
Perdita Henry and Jean Klewitz chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, CAE
advertising sales associate
Michael Conwell
CONTRIBUTING EDITORS Heather Bellino Melissa Benavides, MD Evelyn Delgado Cynthia Y. Herrera, JD Sheri Porter Anita Ravi, MD, MPH, MSHP Kelly Thorstad, MD
SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2018 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6
TEXAS FAMILY PHYSICIAN [No. 4] 2018
if you have never seen the movie “Apollo 13,” I highly recommend it. It tells the story of a fateful NASA mission to the moon. In route to the moon, there was an explosion and the astronauts had to use the lunar lander module as a lifeboat. The movie tells the story of innovation, teamwork, and unbridled commitment toward the goal of bringing the astronauts home. The mission was called “a successful failure” because they failed to go to the moon, but they succeeded in bringing the astronauts home alive against terrible odds. In my role as medical director of population health for my local health system, I have undertaken the task of developing a behavioral health program with the goal of having a behavioral health counselor embedded in each of our primary care clinics and psychiatrist consultants available to review behavioral health care plans, discuss cases with primary care physicians, and receive direct referrals. This is one good way to provide support to primary care while protecting a psychiatrist’s time to ensure that referrals are done for only the most difficult mental health patients. This has been my initial plan for mental health expansion in my organization. Yet as I have proceeded, I have run across more barriers than any other project I have worked on in my career. I was reminded of a scene in the movie “Apollo 13” when they were discussing the use of the lunar lander module to make course corrections for the entire spacecraft in open space. Clearly the lunar lander was not designed to do that. There was a beautiful quote in that movie from the mission commander when he says: “I don’t care what anything was designed to do. I care about what it can do.” In regard to my behavioral health project, I have come to conclude that I have to continue searching for the golden nuggets of things I can do. There is certainly a full dose of things that are the opposite.
For example, I can’t bill the behavioral health collaborative care codes in any of my clinics that have provider-based billing. While I have support from my boss to add psychiatrists and counselors into the next budget, I am tasked with building a business case to add a service line to the organization that has an unfavorable financial return on investment within the broken payment structures available today. For the one social worker in whom we have already invested, I am having much difficulty with the regulatory requirements of having her direct bill for her services. She is not credentialed with health plans; she is not listed as billing with us in the national database; we do not have any behavioral health payer contracts. Because of these challenges, there is a strong desire by some to just keep doing things the way we are doing them now. Yet to borrow another inspiration from “Apollo 13,” we have a new mission, and it’s time to figure out how to do things differently. Our social worker wants to train licensed professional counselor students and social worker students in one of our clinics but we have never done that before. That has raised a whole new set of questions. Do we have an organizational standard in other regions? Is there a legal standard? What is the industry standard? While it took weeks to answer these questions, we thankfully have this issue resolved in my health system. In response we have now added a low-cost behavioral health resource that in the future may expand behavioral health services to additional pods in that clinic location. We discussed adding telepsychiatry services to our facilities but having our mental health patients managed by a psychiatrist is only one part of our clinical need. We also need a psychiatrist to work collaboratively with our primary care physicians, giving advice over the phone and reviewing psychi-
Reiner Consulting & Associates Practice ManageMent ServiceS atric care plans. We will have to be creative if we intend to adapt a telepsychiatry model to meet these additional requests. During the Apollo 13 mission, the carbon dioxide levels were rising dangerously. The lunar lander module was not designed to support three astronauts, nor did they plan to be in it as long as they now needed to be. They did not have any round carbon dioxide filters for the lunar lander module onboard, so they had to adapt the square carbon dioxide filter from the main spacecraft to fit into the lunar lander. A group of specialists were asked to make a square carbon dioxide filter fit into the space for a round filter. Someone took a box of random spacecraft elements and dumped it onto the surface of the table. The line from the movie was simply this: “We gotta find a way to make this fit into the hole for this, using nothing but that.” This quote might as well describe my behavioral health project experience. Yet I remain undeterred. To borrow one final line from “Apollo 13”: “Failure is not an option.” This issue is simply too important — and the benefits too significant — for us to fail. I am not going to stop until we have success in adding mental health resources to our organization. Yet what about the rest of you? TAFP cares about meeting this need for all of our constituents, not just those with a supportive infrastructure from a large health system. How do we get this kind of support for all our members? One key finding from the TAFP strategic planning retreat this summer was clear consensus from all participants that more needs to be done to support behavioral health infrastructure for our members all across Texas. TAFP plans to convene a behavioral health task force to tackle this issue. Perhaps if the task force also uses innovation, teamwork, and unbridled commitment as foundational to its mission, they will also “bring the astronauts home.” It is time to turn Texas’ behavioral health mission into a successful failure. A failure because it has failed our communities for far too long. A success because we rose to the challenge and made a real difference to meet the behavioral health needs in the communities we serve.
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TEXAS FAMILY PHYSICIAN [No. 4] 2018
ABFM to pilot alternative to board exam By Jonathan Nelson consuming, and anxiety-producing highat this year’s aafp Congress of Delegates in stakes exam required for continuing board New Orleans, the American Board of Family certification,” she says. “The new longitudiMedicine announced plans to pilot a longinal assessment, being consistent with adult tudinal assessment alternative to the 10-year learning theory, provides a much better secure examination family physicians must approach. Physicians find more value in take to maintain board certification. This keeping up with current literature by being option will be available to physicians who are tested longitudinally on new knowledge current with continuous certification and as it occurs. Having the are due to take the exam opportunity to answer in 2019. questions conveniently Based on ABFM’s on your own time, with popular Continuous your own device, wherKnowledge Self-Assessever you want simpliment platform, the new fies the process, and assessment option will eliminates the expense of deliver 25 questions travel to testing centers.” online each quarter to Diplomates who pardiplomates who choose ticipate in the longitudito participate. nal assessment will also “This approach is more be able to consult clinical aligned with the ongoing references while answerchanges in medicine and ing the questions each draws upon adult learnquarter, so physicians can ing principles, combined access information just with modern technology, like they do in practice. to promote learning, “It’s what we’ve been retention and transfer of asking for, and it evens information,” Jerry Kruse, the playing field by alignMD, chair of the ABFM ing with the reasonable Board of Directors said requirements of other spein an October 9 ABFM cialty boards,” Hart says. release. “Over time, we The pilot program will be able to assess the was approved by the core clinical knowledge ABFM Board of Directors of board-certified family — Warren Newton, MD in September and it is physicians and recognize expected to be approved the vast majority who by the American Board work to keep up to date to of Medical Specialties’ take care of their patients.” Committee on Continuing Certification in The announcement marks a milestone in November. the evolution of the specialty’s maintenance “We believe that longitudinal assessment of certification program. In July of 2017, AAFP can meet many of the needs and desires we established a task force to evaluate alternative have heard voiced by family physicians,” methods of achieving ongoing board certificasaid Warren Newton, MD, incoming ABFM tion. The group delivered its recommendapresident and CEO, in the release. “It will tions to the AAFP Board in July of this year. provide questions on a regular, longitudinal TAFP President-elect Rebecca Hart, MD, basis, in a format that is much more conserved on the task force and is excited about venient — a few questions at a time, in the the new alternative. “Most family physicians place and time of your choice.” were unhappy with the expensive, time-
“We believe that longitudinal assessment can meet many of the needs and desires we have heard voiced by family physicians. It will provide questions on a regular, longitudinal basis, in a format that is much more convenient — a few questions at a time, in the place and time of your choice.”
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TEXAS FAMILY PHYSICIAN [No. 4] 2018
Houston FP named AAFP executive of the year clive fields, md, of Houston won AAFP’s Robert Graham Physician Executive of the Year Award at this year’s Family Medicine Experience in New Orleans, Louisiana. The award recognizes Fields as a visionary physician executive who has made significant contributions to the specialty of family medicine, promoting higher-quality, cost-effective care in communities across the U.S. “Dr. Fields’ tireless efforts have demonstrated that family physicians can — and should — lead the fundamental changes that are needed in our nation’s health care system,” said Michael Munger, MD, AAFP Board Chair. “He has truly made a difference in his community and beyond, and he has set a high standard as a family physician leader.” Fields is currently president of Village Family Practice, a Houston-based, multisite practice with a team of more than 50 family physicians and other providers. He has been spearheading value-based care at Village Family Practice since the early 1990s. Village Family Practice is recognized as one of the nation’s highest performing groups by CMS for its quality of care. It is also recognized as an NCQA Level 3 medical home. In 2013, Fields parlayed his expertise as both a clinician and physician executive and co-founded VillageMD. This organization provides data analytics, physician-based care coordination and support services to
more than 2,500 primary care physician partners across six states. VillageMD also provides family physicians access to valuebased reimbursement contracts that reward physicians for delivering high-quality, costeffective care. “It is an honor to be recognized by the AAFP as the recipient of this year’s Physician Executive of the Year Award. It is personally humbling to be recognized for my work, but even more importantly, I am proud to be part of the increasing impact primary care physicians are having on our health care system, and one of the many physicians who believe that primary care is the most effective place for health care innovation, driving improved clinical outcomes and health care affordability,” he said. Fields has successfully navigated the ever-changing payment models, from HMO-capitated fees, to fee-for-service, to value-based payments. He played a major role in the creation of the Accountable Care Coalition of Texas and continues to serve on its board of directors. Fields has changed the way health care is delivered in the Houston area. He has served as a mentor to countless family physicians and continues to precept medical students. He has worked across the health care system to bring primary care to the forefront of heath care and inspire future generations of family physicians.
Ferrer elected to National Academy of Medicine The National Academy of Medicine robert l. ferrer, md, mph, has been serves alongside the National Academy elected to the prestigious National Acadof Sciences and the National Academy of emy of Medicine, the academy announced Engineering as an independent adviser to on October 15, 2018. NAM recognized the nation and the international commuFerrer for his work in community health. nity. Membership in the National AcadHe is the eighth faculty member in UT emy of Medicine is considered one of the Health San Antonio history to attain this highest honors in the fields of health and distinction, according to the university. medicine and recognizes individuals who “I’m honored and delighted to be have demonstrated outstanding profeselected to the National Academy of Medisional achievements cine,” Ferrer said. “I and commitment to look forward to the service. opportunity to conFerrer is a tribute to national “I’m honored and practicing family policy discussions delighted to be physician in UT with insights Health San Antoderived from work elected to the National nio’s Joe R. and in primary care Academy of Medicine. Teresa Lozano Long and public health I look forward to School of Mediin our San Antothe opportunity to cine. He is active in nio community. I community health owe a great deal to contribute to national initiatives, servmy many talented policy discussions ing as chair of the colleagues and the with insights derived leadership team for stimulating environfrom work in primary San Antonio’s Comment at UT Health munities Putting San Antonio.” care and public health Prevention to Ferrer focuses on in our San Antonio Work grant from understanding and community. I owe a the Centers for measuring practical great deal to my many Disease Control opportunities for and Prevention. healthy behaviors to talented colleagues He is also a board improve health and and the stimulating member of the well-being in vulenvironment at UT Bexar County nerable populations, Health San Antonio.” Health Collabaccording to a UT orative, serving as Health San Anto— Robert L. Ferrer, MD, MPH board chair for 2016 nio statement. He and 2017. applies an analyti“We are very cal framework that proud of this explores the practirecognition,” said Carlos Roberto Jaén, cal opportunities and capabilities people MD, PhD, professor and chairman of have to achieve the goals they value. the Department of Family and Com“Primarily, interventions have focused munity Medicine in the Long School of on increasing individuals’ knowledge, Medicine. “Dr. Ferrer, through partnermotivation, and self-efficacy,” Ferrer said ship with multiple community groups, in a paper published in the Annals of models for us the healing and empowerFamily Medicine in 2014. “Much eviing functions of primary health care, dence shows, however, that success will bringing together family medicine and be limited if social and environmental public health. He is an excellent percontexts are not accounted for. … The sonal physician and a grounded leader challenge is to understand how to help in community health at the school of a specific patient succeed in a specific medicine.” environment.”
Chassay honored as distinguished alumnus Mark Chassay, MD, MBA, won the Distinguished Alumnus Award of McGovern Medical School. Established in 1987, the award recognizes outstanding contributions of alumni in the areas of medical science and education, or the prevention and treatment of diseases, as well as continued interests in McGovern Medical School and its students. Chassay is an assistant professor in the Department of Orthopedic Surgery and the Department of Family and Community Medicine. He also serves as the associate dean for Alumni Relations and Continuing Medical Education and assistant dean for Admissions and Student Affairs. Chassay received his undergraduate degree from The University of Texas at Austin and attended McGovern Medical School, where he also completed his Family Medicine residency. He completed a fellowship in Primary Care Sports Medicine at Kaiser Permanente in Fontana, California. Chassay holds master’s degrees in education, kinesiology and sports medicine from the University of Texas at Austin and completed the Healthcare Executive Master of Business Administration program at the University of Texas Southwestern Medical School at Dallas. Chassay has been involved in numerous professional organizations and sports programs, serving as a team physician for California State University, Riverside Community College, and Arlington High School from 1995 to 1996. He served as team physician and coordinator of sports medicine for the Department of Intercollegiate Athletics for Women for UT Austin until 2005 and served as a clinical assistant professor at the Joe R. and Teresa Lozano Long School of Medicine. From 2003 to 2006, he served as the team medical physician for the Austin Wranglers, an Arena Football League team, and is currently a team physician in the Department of Intercollegiate Athletics at the University of Texas at Austin. At McGovern Medical School, he established a Primary Care Sports Medicine fellowship. Chassay has held positions with the American Academy of Family Physicians, the American Medical Society of Sports Medicine, and TAFP. “His years of private practice experience helped him to rapidly become one of the most effective faculty at McGovern Medical School,” one of his nominators wrote. “His involvement with alumni as associate dean of Alumni Relations and with recruiting future physicians as assistant dean for Admissions and Student Affairs will continue to bring prestige.” www.tafp.org
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PRACTICE MANAGEMENT
Add AAFP Virtual Care to your family medicine practice Boost access, increase revenue with telemedicine By Sheri Porter
T
he AAFP has launched a new telemedicine software platform designed specifically for family physicians working in small and medium-sized practices with fewer than 20 physicians. Called AAFP Virtual Care, the platform is powered by the virtual care technology company Zipnosis and aims to provide physicians and their patients with an easy way to connect. This new member resource comes at a most opportune time, according to Steven Waldren, MD, director of AAFP’s Alliance for eHealth Innovation. “We’ve seen a significant increase in the adoption of telemedicine across the United States, with the number of visits accelerating exponentially,” Waldren told AAFP News. In fact, about 20 percent of AAFP members currently use telemedicine in some fashion, and that number is growing, he added. America’s health care consumers are showing a strong interest, as well. “Patients, including many seen by family physicians, are looking for access to telemedicine, and there are plenty of commercial entities out there willing to provide that service to consumers,” Waldren said. “Physicians and nurse practitioners with licenses in multiple states are able to sit in an office somewhere and provide telemedicine to patients with whom they have no established relationship at all,” he added. “The AAFP wants to ensure that family physicians can compete against those freestanding telemedicine services so that patients will get the longitudinal care they need and deserve,” Waldren said.
HOW IT WORKS The telemedicine platform is easy to use. Patients enter a website branded to a physician’s medical practice — think of it as a virtual storefront — and request a telemedicine visit. 12
TEXAS FAMILY PHYSICIAN [No. 4] 2018
The patient is prompted to complete a brief online interview detailing the chief complaint and asking further questions. If for instance, she describes pain on urination, the application asks her about flank pain, fever, etc. “The point is to rule out pyelonephritis or some other complication that would indicate the need for an office visit rather than treatment in an asynchronous manner,” Waldren said. After all the appropriate information has been gathered, the practice is notified that a virtual visit has been established. “The physician signs in to see all the information the patient has relayed and, in this instance, easily diagnoses an uncomplicated female urinary tract infection,” Waldren said. Other common conditions appropriate for treatment via AAFP Virtual Care include allergies, influenza, low back pain, conjunctivitis, shingles, and other minor skin conditions, such as eczema and contact dermatitis. In the example cited above, once a diagnosis is indicated, the tool provides a list of appropriate antibiotics for a UTI, generates a note for the patient’s chart and creates a patient handout describing what needs to be done. If a prescription is required, the patient picks a pharmacy from a list provided and the script is sent to the pharmacy through Surescripts to be filled.
SIGN UP TODAY FOR AAFP VIRTUAL CARE Family physicians who have been eyeing telemedicine as an opportunity to expand patient access to quality care and increase revenue flow will be pleased to hear that AAFP Virtual Care is up and running full speed ahead. Members can sign up today and see what a difference telemedicine can make.
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“Physicians and nurse practitioners with licenses in multiple states are able to sit in an office somewhere and provide telemedicine to patients with whom they have no established relationship at all. The AAFP wants to ensure that family physicians can compete against those freestanding telemedicine services so that patients will get the longitudinal care they need and deserve.” Steven Waldren, MD AAFP Alliance for eHealth Innovation
“It takes on average less than two minutes for the physician to review everything, perform the medical decision-making, take action, document and provide patient education,” Waldren said. The asynchronous visit described above is often the most beneficial to practices and patients because it doesn’t create much disruption in the physician’s workflow, he said. “If a particular patient warrants some additional discussion, or the physician really needs to see ‘the whites of the patient’s eyes,’ the application can step that patient up to a video visit,” Waldren said. In addition, an automatic triage function kicks in based on a patient’s initial responses to questions. “If that patient said she had fever and flank pain, she would have gotten a message directing her to contact the physician’s office immediately or to go to an urgent care clinic,” noted Waldren.
PRAISE FROM A FAMILY PHYSICIAN Family physician Robert Patterson, MD, of Sanford, North Carolina, has been testing the AAFP Virtual Care platform for months and couldn’t be happier. “It works great and is a wonderful tool for my patients that need me but do not have time to leave home or work to come see me. Also, folks who just plain do not feel like driving to the office can get care,” he told AAFP News. Patients use the service for a variety of issues. “They see me virtually for rechecks, skin lesions, discussions of lab work, urgent medical issues like colds, sinuses, UTIs, gastroenteritis, and more. Patients are happy because the visit is cheaper than alternatives, and they can be ‘seen’ by their normal doctor who knows them,” Patterson said. Patients also appreciate the convenience factor and expanded hours. As for the physician’s bottom line, there are perks there, as well. “Right now, virtual care adds six to 10 patients to my schedule each day, and it actually makes my day easier. It also cuts overhead as I require less staff assistance with this.”
RETURN ON INVESTMENT Only AAFP members and other physicians and health care professionals working in a member’s practice are eligible for AAFP Virtual Care. Practices must sign on for a 12-month term. The cost works out to as little as $159 per month for each authorized clinician user plus a onetime setup fee. Complete pricing and payment options are available in an FAQ that also answers a myriad of other questions about the virtual care platform. Importantly, physicians do not bill this service through insurance; rather, each practice determines how much to charge patients for asynchronous and video visits. “Patients are paying for this service out-of-pocket and are doing so willingly,” Waldren said. As for physicians, “If they charge in the $30 range, they would need to conduct just over six virtual visits per month to pay for the service for the year.” Waldren said he knows of a family physician who charges $75 for an asynchronous visit and $100 for video visits. “He saw his return on investment in the first month and will make money on the venture the rest of the year.”
Source: AAFP News, September 12, 2018. ©2018 American Academy of Family Physicians. 14
TEXAS FAMILY PHYSICIAN [No. 4] 2018
“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient
www.TAFPPAC.org
MY PATIENTS ARE AFFECTED BY
INTIMATE PARTNER VIOLENCE
— AND YOURS ARE, TOO! By Kelly Thorstad, MD, Heather Bellino, and Cynthia Y. Herrera, JD
one of the most unsettling feelings I have had as a physician is when my gut tells me a patient isn’t safe. Treating their physical injuries is one thing, but truly helping a victim of domestic violence goes well outside my medical training. Their injuries are not just medical, and the solutions I can offer must go beyond my daily routine. I cannot heal them alone. I am grateful to have found community partners that offer legal services, shelter, and counseling to create a coordinated community response. This team-based approach has been an invaluable tool in improving health outcomes for my patients. There are things we have to do when we suspect intimate partner violence, such as providing resource information to the survivor, as required by law, and mandatory reporting of abuse against children, elderly, and disabled patients. There are also things we should do, like partnering with community organizations to build healthier societies. I work with Texas Advocacy Project, a statewide organization whose mission is to prevent domestic and dating violence, sexual assault, and stalking throughout Texas through free legal services, access to the justice system, and education. As a pediatrician, one of my favorite things about the Project is their commitment to teaching teens about healthy relationships. Perhaps this pay-it-forward mindset of empowering our youth is the only way we can tackle such a prevalent and horrible epidemic in our society. But for now, I will be comforted when I hear Texas Advocacy Project say, “We’ve got this.”
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TEXAS FAMILY PHYSICIAN [No. 4] 2018
www.tafp.org
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What is intimate partner violence? Intimate partner violence, or IPV, is generally recognized as a pattern of behavior and tactics used to gain or maintain power and control over a current or former intimate partner that can include physical, sexual, emotional, economic, or psychological abuse or threats of abuse. The Centers for Disease Control and Prevention have adopted a uniform definition of intimate partner violence that includes physical violence, sexual violence, stalking, and psychological aggression, including coercive tactics.1 The concept of intimate partner violence acknowledges that abuse can exist in any type of personal intimate relationship, regardless of sexual orientation, marital status, or gender. It’s important to stipulate at the outset that the term does not assign the roles of the abuser and victim to one gender, and that the term is often used interchangeably with “domestic violence” and “family violence.” The legal definition of intimate partner violence in the state of Texas is more narrowly defined. Texas refers to intimate- partner violence as “family violence” and includes only physical violence, sexual assault, or threat of either.2 Meanwhile, state law also encompasses a wider range of relationships to define an actor of family violence as any member of a family or household. That means that roommates and family members of blood relation who do not cohabitate with the victim are included. The differences in these definitions are important when determining what legal remedies may be available to a patient affected by intimate partner violence. However, even if one of your patients is experiencing abuse outside of the state law definition, legal relief and advocacy may still be available. Partnering with local legal services organizations that specialize in intimate partner violence is important so that a legal expert can help make that determination for each individual patient and their unique circumstances.
Health consequence of intimate partner violence throughout the lifespan We know a patient’s health is heavily influenced by his or her environment. The patient’s home, workplace, school, family, and income all play a role in health outcomes. These factors, sometimes referred to as “social determinants of health,” are the conditions in which people are born, grow, live, work, and age.3 What happens when intimate partner violence is added to the mix? Intimate partner violence can cause severe and pervasive health consequences including physical injury, psychological trauma, and even death.4 One in three Texas women will experience domestic violence In 2017, 136 women were killed by their intimate partner.5 Physical injuries, unintended pregnancy, sexually transmitted infections, drug and alcohol use, and post-traumatic stress disorder are just some of the consequences that patients affected by intimate partner violence may suffer.6 Pregnancy and intimate partner violence Women are particularly vulnerable to intimate partner violence during and around pregnancy due to heightened relationship stress and the increased physical, social, emotional, and economic demands 18
TEXAS FAMILY PHYSICIAN [No. 4] 2018
of pregnancy.6 Studies show that 25 to 45 percent of all women who are battered are battered during pregnancy.7 Intimate partner violence during pregnancy significantly impacts pregnancy outcomes and can lead to lower gestational weights, low birth weights, preterm births, and higher rates of postpartum depression.6 Pregnant patients may also experience a form of intimate partner violence that has led to an unintended pregnancy. Reproductive coercion includes overt force and direct interference with contraception such as limiting a woman’s access to contraception, destroying birth control pills, breaking condoms or diaphragms, and removing contraceptive rings or patches. Reproductive coercion is prevalent in 32 percent of pregnant survivors of intimate partner violence.7 Childhood and intimate partner violence An estimated 275 million children worldwide and 16.3 percent of U.S. children younger than 17 years of age witness physical assaults between their adult caretakers in their lifetime with children under the age of 5 years being more likely to witness adult violence.6 Children exposed to IPV are 2.6 times more likely to be physically abused and 9.6 times more likely to be psychologically abused than children without such exposure.6 The health consequences of exposure to IPV can be physical, ranging from poor weight gain and irritability to delayed milestones and under-immunization.6 Psychosocial effects also pose a risk of harm to children exposed to IPV.6 Internalized behaviors such as depression, eating disorders, and self-harm are commonly seen, as well as externalized behaviors like antisocial behaviors, aggression, and bullying.6 Additionally, children’s exposure to IPV is associated with victimization and perpetration of relationship abuse in adolescence.6 Teens and intimate partner violence One in three adolescents in the U.S. is a victim of physical, sexual, verbal, or emotional abuse from a dating partner.8 Teens often experience specific kinds of intimate partner violence, such as digital dating abuse and bullying. Digital dating abuse is defined as being verbally and emotionally abusive while using technologies such as texting and social networking to bully, harass, stalk, or intimidate a partner.8 In many of these cases, an abusive dating partner might demand or pressure your patient for sexually explicit materials, send unsolicited communication, or blackmail your patient with sexual content.8 One in four teens is harassed or abused in these ways through technology and 52 percent of teens who experience digital abuse are also physically abused.8 The elderly and intimate partner violence Intimate partner violence against the elderly takes various forms including physical harm, sexual assault, and murder.9 Caregiver stress, alcohol use, and the poor health of the victim, in general, have been cited as factors contributing to violence in later life.9 In general, elder abuse may go undetected. For every one case of elder abuse or neglect that is reported, five go unreported.9 At least one study has found that strangulation (as the cause of death) increases in frequency with the victim’s age.10 Suffocation homicide of elders is difficult for law enforcement to detect.10 Strangulation and suffocation, which also occur at a greater frequency in domestic violence relationships, may be fatal without external evidence of injury.10
The physician’s response to intimate partner violence Intimate partner violence is a preventable public health epidemic that adversely affects our patients.1 As physicians, we have the power to intervene, to mitigate, and even to prevent ongoing intimate partner violence and its effects on our patients. Physicians are specially positioned to reduce incidents of IPV As health care providers, we are in a unique position. We regularly interact with patients who may not otherwise engage community services. Our patients already trust us and are already telling us about their well-being and the challenges they face in life. For your patients, this may be the only place they feel safe to disclose abuse. We can save lives we may not even know are in danger by incorporating prevention and intervention strategies into our practices. Create a safe place for disclosure and education Making your practice a safe place for patients to disclose intimate partner violence is essential. Your office should communicate broadly with patients that it is a place where they can discuss and learn about options to address intimate partner violence, without fear of retribution or the risk of not being believed. Materials, such as signage and brochures, offering information about intimate partner violence and its impact on patient health and on the health of patients’ children should be prominently displayed. Many community organizations provide these types of materials free of charge for use in your practice. Education on IPV in the health care setting is imperative. This invaluable information raises both the patient’s health literacy and their awareness of intimate partner violence.6 Even if at the time of a visit the patient is not involved in an abusive situation or is not ready to disclose, she or he will be more receptive to the next opportunity to receive information or to participate in a screening.6 Effectively screen for intimate partner violence The U.S. Preventive Services Task Force, American Congress of Obstetricians and Gynecologists, American Academy of Family Physicians, and the American Academy of Nursing recommend routinely screening all women of child-bearing age for domestic violence.6 We can detect or identify patients affected by IPV by being alert to warning signs of victimization or by screening patients for victimization. However, it is important for us to recognize and to understand that not all victims of intimate partner violence present outward signs of abuse. In fact, best practices suggest health care providers add information about domestic violence and screenings to routine visits (e.g., prenatal visits, post-partum depression screenings, and vaccinations).6 For most effective results, it is recommended that we invite IPV experts to join in the development of policies for screening or for the selection of a screening tool.6 Recognition and validation of a patient’s experience with intimate partner violence is a critical first step in safety planning. It reduces isolation and shame and encourages the patient to believe that a better future is possible. Patients are four times more likely to use an intervention when they talk to their health care provider about abuse.11 And, women who talked to their health care provider about abuse have been shown to be 2.6 times more likely to exit the abusive relationship.12
As health care providers, we are in a unique position. Our patients already trust us and are already telling us about their well-being and the challenges they face in life. We can save lives we may not even know are in danger by incorporating prevention and intervention strategies into our practices.
Things we must do When your patient discloses intimate partner violence As mentioned earlier, every health care provider is legally required to take certain steps when a patient discloses family violence or when we suspect injuries are caused by family violence. According to the law, any medical professional who treats a person for injuries that the medical professional has reason to believe were caused by family violence is required to (1) give notice to the person regarding the nearest family violence shelter center; (2) document, in the person’s medical file, that the notice was received and the reasons for the medical professional’s belief that the person’s injuries were caused by family violence; and (3) provide notice to the person that family violence is a crime that may be reported to law enforcement and that the person may seek a protective order from the court with certain types of relief.13 A well-documented medical record can help attorneys win court cases against the abuser. Mandatory reporting When the violence manifests as child abuse or neglect, we know we are all mandatory reporters. We should be reminded that we are also required to report abuse, neglect, self-neglect, and exploitation of the elderly or adults with disabilities. These reports should be made to the Texas Department of Family and Protective Services by calling (800) 252-5400 (anonymity can be maintained) or reporting online at the Texas Abuse Hotline website, www.txabusehotline.org.14 Every health care entity should have a protocol for responding to disclosures of intimate partner violence. This protocol should include how to provide information to patients on how to access the nearest shelter, how to seek services through local community resources, such as Texas Advocacy Project,15 which can be called at (800) 374-HOPE, and how to report the crime to local law enforcement. Ultimately, connecting survivors to needed services and intervening to diminish the impacts of abuse are the keys to effectively addressing intimate partner violence.
Things we should do Address health-harming legal needs with a medical-legal partnership Traditionally, attorneys and doctors do not regularly work together. However, a medical-legal partnership, or MLP, turns that tradition on its head, encouraging the integration of attorneys in the health care setting. This innovative model provides patients with the wrap-around services they need to help them overcome those barriers to health that often hold them back from following through with the health plans we craft for them. An integrated health care system better addresses health-harming social needs by leveraging the unique expertise of attorneys into health care settings to help clinicians, case managers, and social workers address structural problems at the root of so many health inequities.3 Knowing and forming relationships with local community organizations that specialize in intimate partner violence services is a critical component in creating the coordinated community response your patients need. An attorney can offer legal solutions for many issues that prevent patients from attaining optimal health outcomes. The following are examples of the legal relief for which a patient may be eligible, and that will make them healthier in the long term. 20
TEXAS FAMILY PHYSICIAN [No. 4] 2018
WHERE TO REPORT INTIMATE PARTNER VIOLENCE Texas Department of Family and Protective Services (800) 252-5400 Texas Abuse Hotline website www.txabusehotline.org Texas Advocacy Project (800) 374-HOPE
I. Safety – A patient experiencing intimate partner violence feels unsafe because of the presence of an abuser in the home. An attorney can help your patient apply for a protective order with the court. A protective order may prohibit the abuser from staying in the home or from coming near the applicant and from harassing or threatening the applicant. If violated, the police are required to arrest and charge the abuser for violation of a protective order for each incident, even if no other laws are broken. Protective orders have been shown to help keep applicants safer and to reduce incidents of intimate partner violence. II. Privacy – Your teenage patient is having suicidal ideations because a nude photo may be circulated amongst her classmates if she breaks up with her abusive boyfriend. An attorney can help your patient seek an injunction to prevent revenge porn. III. Employment – Your patient is affected by sexual harassment and is fired when she speaks out at work. She loses her health insurance coverage. An attorney can help your patient launch an investigation against the employer, based on gender discrimination, and get coverage restored as a term of conciliation. IV. Family law – Your patient discloses that she is pregnant as a result of a rape and she is concerned about the rapist’s access to the child. An attorney can help your patient terminate parental rights to sever any legal relationship between the child and the biological father. V. Education – Your minor patient exhibits effects of bullying at school. An attorney can advocate that the school impose a stay-away agreement and any other accommodations needed, as required under Title IX. VI. Housing – Your patient discloses that she was raped in her home and no longer feels safe at her apartment complex. An attorney can help terminate her lease with no financial repercussions. VII. Financial – Your patient is struggling to pay her child’s medical bills because the non-custodial parent has failed to pay his half of uninsured health expenses. An attorney can help your patient seek an order to garnish the non-custodial parent’s wages to cover unpaid health expenses.
While it is important that we as physicians understand the breadth of legal relief an attorney can offer, it is not our job to act as an attorney. A medical-legal partnership is key because it allows each professional the opportunity and the ability to work at the top of their licenses. Attorneys focus on providing civil legal remedies while health care providers can focus solely upon delivering optimal health care in an environment where social determinants of health are adequately addressed and do not pose insurmountable barriers to desired health outcomes.
Be a health care champion! Intimate partner violence is pervasive and may seem insurmountable. In reality it is a preventable public health epidemic. If we take the needed steps to integrate community services into our practices, we will save more lives and improve health outcomes for our patients in a way that we would never be able to do otherwise.
REFERENCES 1. Centers for Disease Control and Prevention. Available at: https:// www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html. 2. Texas Family Code 71.004 (1997). 3. National Center for Medical Legal Partnership. Available at: https://medical-legalpartnership.org/. 4. Antai D. Traumatic physical health consequences of intimate partner violence against women: What is the role of communitylevel factors? BMC Women’s Health. 2011. 5. Texas Council on Family Violence. Available at: http://tcfv.org/ resource-center/learn-the-facts/. 6. Task Force on Domestic Violence Report. As required by H.B. 2620, 83rd Legislature, Regular Session, 2013. Health and Human Services Commission, September 2015. 7. Violence against pregnant women; Prevalence, patterns, risk factors, theories, and directions for future research. Tallieu, T.L. and Brownridge, D.A. 2010, Aggression and Violent Behavior, Vol. 15, pp. 14-35. 8. Loveisrespect. Available at: https://www.loveisrespect.org/ resources/dating-violence-statistics/. 9. Roberto KA, McCann BR, Brossoie N. Intimate Partner Violence in Late Life: An Analysis of National News Reports. J Elder Abuse Negl. 2013. 10. Dean A. Hawley, M.D. Injuries of Fatal and Non-fatal Suffocation in Family Violence Cases. 11. Marsha Regenstein, Jennifer Trott, and Alanna Williamson. Report: Findings from the 2016 NCMLP national survey on MLP activities and trends. 2017. 12. McCloskey LA, Lichter E, Williams C, Gerber M, Wittenberg E, Ganz M. Assessing intimate partner violence in health care settings leads to women’s receipt of interventions and improved health. Public Health Rep. 2006. 13. 13. Tex Fam Code 91.003 (1997). 14. Texas Department of Family and Protective Services. Available at: https://www.txabusehotline.org/Login/Default.aspx. 15. Texas Advocacy Project. Available at: https://www.texasadvocacyproject.org/.
Making your practice a safe place for patients to disclose intimate partner violence is essential. Your office should communicate broadly with patients that it is a place where they can discuss and learn about options to address intimate partner violence, without fear of retribution or the risk of not being believed. Texas Advocacy Project is a statewide non-profit organization providing legal solutions to victims of domestic violence and sexual assault. Visit their website at www.texasadvocacyproject.org. www.tafp.org
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I N T RO D U C I NG
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AAFP FRESH PERSPECTIVES
Advocating for our patients in the #MeToo era Words and illustrations by Anita Ravi, MD, MPH, MSHP
the burden of fighting the culture of sexual violence does not and cannot lie solely on survivors. It must include the voices of physicians. The 2018 Nobel Peace Prize recipients offer a beautiful example of this dual effort. Denis Mukwege, MD, PhD, and activist Nadia Murad — herself a survivor — were both recognized for their efforts to end the use of sexual violence as a weapon of war. Three years ago, I started what you might call a #MeToo family medicine clinic. The PurpLE Clinic at the Institute for Family Health in New York, New York, was designed for people who have experienced sexual trauma, including sexual assault, domestic violence, and sex trafficking. Every criticism from the outside world, from “Why didn’t she report it?” to “What if she’s lying?” can be answered inside the clinic. And yet, when I leave the confines of the medical space, I see these questions stubbornly fester in public discourse, exploiting the silence and circumstances of sexual trauma survivors. As a doctor, I am compelled to counter the harmful misconceptions regarding sexual violence and trauma with truths that I have learned from clinical practice. Here are a few. STORYTELLING My clinical exam room is a graveyard of smashed stereotypes of what some people think victims should be — a distressed individual who provides a linear story with a desire to report the assault immediately. Recounting a sexual assault is nonformulaic. Stories may come out as you make contact with the doorknob to leave the exam room, when you are about to begin a Pap smear, or when you have just placed a stethoscope on the heart. They may spill out hours after an assault or 20 years later. They may be the reason for a medical visit, or they may unexpectedly come up when you talk about diet and exercise and hear, “I tried to gain weight and stopped wearing makeup so I wouldn’t be raped again.”
As physicians, our responsibility to counter rape culture is not simply to share stories, but to share how our patients share their stories. We must lend credence to the unexpected smiles, inevitable gaps in memory, and nonlinear information that is normal in trauma. The first sexual assault exam I ever did was with a teenage girl. She had never had a speculum exam. I asked if anything would make her feel more comfortable. She turned on her iTunes, and we started her exam with music blaring in the background. She had come in with her best friend. They laughed and giggled together. Her assault had occurred just seven hours earlier. That is trauma. Our public awareness must evolve to understand trauma’s permutations so survivors are not wrongly scrutinized. PHOTOS “But they looked so happy” is a common reaction when people learn that someone they know was in an abusive relationship. There are pictures seen by the outside world — images of a healthy, loving relationship, beautifully curated and filtered photos on Facebook and Instagram. And then there are the photos I take in clinic. Smiles to the external world are irrelevant in the confines of the exam room. Every time I meet someone who has experienced a recent sexual assault or domestic violence, I ask two questions: “Do you plan to file a police report?” and “Would you like photos of the injuries in your medical record?” The answer is almost always “No” to the first and “Yes” to the second.
Photographing injuries remains a particularly unnatural and emotionally challenging part of my work. The silence during the 10-second process of setting up the camera always grows uncomfortably large. Sometimes she helps hold the ruler, noting my clumsy efforts to measure the injury while photographing. I press the button. And then I move to the next one. I hope that this process will never feel normal. And I hope that our public consciousness evolves to understand that the presence of happy pictures does not imply an absence of trauma. www.tafp.org
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RÉSUMÉS Sexual assault is the abuse of power. It can be power based on many factors: gender, race, sexuality, immigration status, literacy, mental health, and on and on. When an accused person lists an illustrious résumé, it tells me about their positions of power but it does not tell me the responsibility with which they wield it. Being educated or wealthy is not a prophylactic against perpetrating violence. People in highly esteemed positions of power have hurt my patients. It’s a common reason that people don’t report the crime. In cases of sexual assault, résumés are not needed. Résumés are also often used to highlight the harm to those who are accused of sexual assault. What if it’s not true? A person’s hard-earned standing in the world has been ruined. Look at what they’ve lost. I wish this remarkable empathy could be applied in understanding the loss that comes with sexual assault. But it’s harder to quantify the loss of opportunities that were never actualized. In medicine, we are taught about “insensible losses” — the loss of fluids from our body that can neither be perceived nor measured directly but are critical to account for. Some sexual assault survivors experience a form of insensible loss on their résumés. The invasion of post-traumatic stress disorder, depression, and anxiety following sexual assault can result in life-altering changes that impact career trajectories. These are financial, physical, and emotional losses that are masked by survivors’ resilience. When asked about their dream job, my patients commonly respond, “I used to want to be X, but now I’d rather be Y.” X has included becoming a business owner, social worker, or health professional, while Y has frequently included wanting to be a mortician or custodial worker — something quieter “where no one harasses you or tells you, ‘Your ass looks nice.’” These résumé changes often go undetected during the “inconvenience” of sexual assault accusation discussions but it’s time for them to be accounted for and acted on in our collective response to sexual violence.
Every time I meet someone who has experienced a recent sexual assault or domestic violence, I ask two questions: “Do you plan to file a police report?” and “Would you like photos of the injuries in your medical record?” The answer is almost always “No” to the first and “Yes” to the second.
WITNESS As each day of clinic wraps up and I step outside, two truths stubbornly, persistently demand my attention on my walk home: Sexual violence is a cultural infection and adding physician voices is necessary for its eradication. Physicians bear witness to the patterns of stories that deserve to influence policies but may never be heard. The shared work of survivors and physician allies is necessary to change our culture and to secure a future immune to sexual violence.
Anita Ravi, MD, MPH, MSHP, is the founder and clinical director of the PurpLE Clinic at the Institute for Family Health in New York, New York. She says she is not an artist but enjoys using stick figures to promote health and gender equity. The editors of this magazine love her art. You can follow her on Twitter @anitafamilydoc.
Source: AAFP Fresh Perspectives, October 9, 2018. ©2018 American Academy of Family Physicians. www.tafp.org
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LEGISLATIVE UPDATE
Advocating for women’s health in the 86th Texas Legislature By Evelyn Delgado Texas Women’s Healthcare Coalition Chair and Healthy Futures of Texas President/Executive Director the texas women’s healthcare coalition is a nonpartisan organization dedicated to improving the health and well-being of women, babies, and families by ensuring access to preventive care — including contraception — for all Texas women. Our membership includes health care organizations, provider organizations, advocacy organizations, and faith organizations from across the state. We strive toward our mission by working with state legislators on women’s health policy issues, educating the public on the landscape of women’s health in Texas, and through building relationships with state agency leaders to improve the programs serving Texas women. Since its formation, TWHC has advocated for priority issues during each Texas legislative session with the goal of improving access to women’s health services. The No. 1 priority is always to protect funding for the state’s women’s health programs and advocate for more funding to meet the statewide need for family planning and preventive health services. At the end of the 85th Legislative Session, we saw the Legislature fund the state’s women’s health programs at the same level as the previous biennium, and at a higher level than actual 2016-2017 expenditures. The Legislature also pushed through several positive bills and riders, including measures that: • improve data collection for the state’s women’s health programs, • study auto-enrolling young women from CHIP and Medicaid into the Healthy Texas Women program, • require the Health and Human Services Commission to develop a strategic plan to increase access to long-acting reversible contraception, and • look at different ways to address the state’s high maternal mortality rates. In the interim, TWHC has been monitoring the implementation of the above positive bills and riders. We also hosted community engagement events to receive input from stake-
holders on successes and challenges with the state’s women’s health programs. Collecting all this information enables us to continue to build support for policy changes not addressed in the last legislative session. In preparation for the 86th Legislative Session, TWHC developed policy priorities to continue working toward a Texas where all women have meaningful access to preventive health care services. The areas of focus are: • funding; • quality provider network; • access to all FDA approved forms of contraception and medically accurate, adequate counseling; and • continuity of care and maximizing the number of women served. FUNDING The primary priority will build on the legislative support shown during the 85th Legislature and focuses on ensuring funding for women’s preventive health care. TWHC wants to ensure the distribution of funding between the state’s women’s health programs matches the need within each program. Especially with no word yet from the Centers for Medicare and Medicaid Services on the state’s application for an 1115 waiver to support the HTW program with federal funds, legislators must keep women’s health a priority as the network of providers is being rebuilt. QUALITY PROVIDER NETWORK Texas needs more providers to deliver preventive care to women, especially in rural areas. The women’s health care safety net is still recovering from cuts to family planning programs in 2011 and the exclusion of some of the state’s largest providers. A consistent piece of feedback TWHC hears from providers is the need for improved provider outreach and trainings. Implementing these programs is a huge administrative task and clinics across the state need timely, consistent, and program-specific support from the agency. In addition to technical assistance, there is inconsistent provider knowledge on program services. Questions still arise on key elements of the HTW program, like auto-enrollment from Medicaid for Pregnant Women into HTW, and covered services. TWHC will seek to promote best practices and adequate provider training. ACCESS TO CONTRACEPTION AND MEDICALLY ACCURATE COUNSELING Ensuring women have access to the most effective form of contraception that works for them is key to enabling women to plan and space their pregnancies. But, access alone is not enough. Providing women with medically accurate counseling on all forms of contraception is just as critical so women have the knowledge needed to decide what is best for them. This is especially necessary in light of the proposed revisions to Title X regulations.
www.tafp.org
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Since its formation, TWHC has advocated for priority issues during each Texas legislative session with the goal of improving access to women’s health services. The No. 1 priority is always to protect funding for the state’s women’s health programs and advocate for more funding to meet the statewide need for family planning and preventive health services.
Instead of providing women access to a comprehensive array of family-planning options, Title X grantees would emphasize “natural family planning” and abstinence. While both are valid choices, they should not make more effective methods less available. Also under these new guidelines, HHS would no longer require clinics to provide medically approved forms of contraception. TWHC does not want to see the state’s women’s health programs adopt similar, concerning changes. CONTINUITY OF CARE AND MAXIMIZING THE NUMBER OF WOMEN SERVED With the recent attention on the high maternal mortality in Texas, providers, lawmakers, and stakeholders from across the state have also been discussing issues around continuity of care. When women can plan and space their pregnancies, they are better able to prepare for possible complications pregnancy and delivery can bring. Maternal health starts well before a woman becomes pregnant, and access to health care, including consistent and effective contraception, can greatly improve health outcomes. Enabling eligible women to access and maintain continuous health care coverage improves health outcomes and reduces costs to the state. TWHC has identified several opportunities to ensure this continuous coverage, including improvements to the HTW autoenrollment feature, applying the HTW auto-enrollment feature to women aging out of Children’s Medicaid and CHIP, and extending health care coverage for women in Medicaid for Pregnant Women to 12-months postpartum. TWHC is committed to exploring solutions to the coverage gap in order to maximize the number of women who are able to access critical preventive services and family planning services before, during, and after pregnancy.
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TEXAS FAMILY PHYSICIAN [No. 4] 2018
Visit: www.CoreContent.com Call: 888-343-CORE (2673) Email: mail@CoreContent.com
Achieve healthier outcomes—for everyone. In its first major development for The EveryONE Project, the AAFP compiled an in-depth toolkit to help physicians recognize and respond to social factors that impact the health of patients. The EveryONE Project toolkit is validated, intuitive, action oriented, and free. Utilize it to: • Raise awareness about the effects of social determinants of health. • Discover specific health risks in patients of all backgrounds. • Understand and manage potential biases that may exist. • Connect patients with essential resources in their area. Reveal and address the unseen health hurdles your patients face every day. Start using The EveryONE Project toolkit now.
aafp.org/EveryONE/tools
The EveryONE Project Advancing health equity in every community
PERSPECTIVE
Family physicians and long-acting reversible contraception By Melissa Benavides, MD there is tremendous need across the state of Texas for increased access to women’s health services. As a physician representing TAFP on the Texas Women’s Healthcare Coalition, I would like to remind my colleagues that family physicians are well positioned to fill this void. Even some of the smaller, more remote towns throughout our state are served by dedicated family physicians who have equipped themselves to provide convenient, wide-ranging women’s health services. As many patients prefer and trust their family physicians, we are in the perfect spot to make positive impacts on the health status of women and children throughout Texas. I would like to address two major steps we can take as family physicians to improve the availability and convenience of women’s health services in our state. First, we can ask all female patients of childbearing age One Key Question: “Would you like to become pregnant in the next year?” The One Key Question campaign was developed by the Oregon Foundation for Reproductive Health to spark conversations about reproductive health among providers and patients. Based on the patient’s answer to this critical question, family physicians can proactively support women who desire to become pregnant with preconception counseling, recommending folic acid and alcohol avoidance, as well as addressing chronic medical conditions prior to pregnancy. If a patient is not ready to become pregnant, we can assist her with contraception so she can prevent pregnancy if she is not financially, emotionally, or physically ready. Second, while most family physicians are comfortable prescribing birth control pills, patches, and injections, many do not yet offer long-acting reversible contraception. LARCs, which include implantable devices such as Nexplanon, and IUDs, are some of the most effective forms of birth control available. When given the option, many patients will choose LARCs as a more reliable, sustained way of preventing unplanned pregnancy. By both 1) asking patients’ their plans for pregnancy and 2) offering LARCs within our clinics, family physicians can achieve widespread positive impacts. For example, the state of Colorado reduced its teen pregnancy rate by 50 percent and its abortion rate by 50 percent by offering LARCs for free and improving access. These two changes are fairly easy to implement, as most family physicians are trained in insertion during residency and LARC procedures are easy to perform within our offices. Even if you have not offered LARCs in your own practice or maintained your skills,
training programs are available to guide effective clinical implementation so you can play a role in increasing access to women’s health services across Texas. Let me share a personal example. I work for Crossover Health, an innovative employer-sponsored health care organization that partners with corporate clients to serve as the preferred medical home for their employees and in some cases, dependents. My local Crossover Health center decided to offer LARCs to our patients last year. To prepare for the new offering, our family physicians took a Nexplanon training class taught by Merck, which is required by Merck to place an order for Nexplanon. We also honed our IUD skills at courses provided during the September 2017 AAFP Family Medicine Experience conference in San Antonio. By November 2017, we were able to offer LARCs to our patients. By starting with the One Key Question — asking about the desire for pregnancy or contraception — at our female patients’ preventive care visits and advising them that we offer LARCs, we have seen tremendous demand. Patients have been very pleased with this service, and because we strive to serve as our patients’ preferred medical home, many have positively remarked on the experience of having the procedure performed by their own physician instead of being referred out. Based on the demand we have seen locally, we hope to offer LARCs at all of our Crossover Health centers in Texas and the rest of the country so we can provide our patients with convenient, accessible care from their most trusted providers. If you are interested in positively improving women’s health services across Texas, there are several ways to get started. Both the TAFP and AAFP offer IUD training courses at conferences throughout the year. Nexplanon training can be arranged directly through Merck. They may be willing to offer a course in a remote area if physicians ask for it. Additionally, LARCs are reimbursed by many private insurers without additional out-of-pocket cost to the patient due to the ACA. They are also covered by Medicaid and the Healthy Texas Women program. By asking all female patients of child-bearing age about their reproductive plans at least yearly and offering a full range of contraceptive options including LARCs, family physicians can help reduce unplanned pregnancies and positively improve the accessibility and convenience of women’s health services across Texas.
By starting with the One Key Question — asking about the desire for pregnancy or contraception — at our female patients’ preventive care visits and advising them that we offer LARCs, we have seen tremendous demand.
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TEXAS FAMILY PHYSICIAN [No. 4] 2018
FAMILY MEDICINE FACULTY OPPORTUNITIES Houston, Texas
Baylor College of Medicine has opportunities for clinical faculty who are board certified/eligible in Family Medicine and interested in providing inpatient services. In addition to joining an outstanding group of faculty who are dedicated to the care of a variety of populations, our faculty enjoy opportunities to participate in academic activities including medical student education and resident education.
APPLY ONLINE: https://www.bcm.edu/careers
This position includes a faculty
FOR FURTHER INFORMATION CONTACT
appointment at a competitive salary with excellent benefits and the opportunity to join a distinguished institution.
ROGER J. ZOOROB, MD, MPH, FAAFP RICHARD M. KLEBERG SR. Professor and Chair DEPARTMENT OF FAMILY & COMMUNITY MEDICINE 3701 Kirby Drive, Suite 600 • Houston, TX 77098 Roger.Zoorob@bcm.edu • 713.798.2555 https://www.bcm.edu/departments/family-and-community-medicine/
APPLY ONLINE: https://www.bcm.edu/careers
Position #: 206796, 211758, 215737, 218426, 219313, 250359 Baylor College of Medicine is an Equal Opportunity/ Affirmative Action/Equal Access Employer
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Bolingbrook, IL Permit No. 467
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By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org.
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