INDIAN HEALTH SERVICE AND OFFICE FOR VICTIMS OF CRIME CHILD ABUSE PROJECT PAST, PRESENT, AND FUTURE

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INDIAN HEALTH SERVICE ANDOFFICE FOR VICTIMS
OF CRIMECHILD ABUSE PROJECTPAST, PRESENT,
AND FUTURE

• CDR P. Jane Powers APRN, BC, MS, FAANP
• Project Director
• SEPTEMBER 2004 PRESENTATION TO INDIAN HEALTH
  SERVICE AND OFFICE FOR VICTIMS OF CRIME
• WASHINGTON, DC

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SPECIAL THANKS AND APPRECIATION

• Cathy Sanders, Acting Director, Federal Crime
  Victims Division, Office for Victims of Crime
• Al Hiat, PhD (Retired), Behavioral Health
  Consultant, Indian Health Service Headquarters
  East
• Indian Health Service Headquarters East
• - Richard Olson, MD, Acting Director,
  OCPS
• - Judith Thierry, DO, Maternal Child
  Health Coordinator
• - Ramona Williams, Social Worker
• Paulette Hansen, Director, American Indian
  Information Network
• Project Faculty
• Second Opinion Software, LLC
• Project Making Medicine, University of Oklahoma
• UO Service Unit

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WHAT IS CHILD ABUSE AND WHAT DOES IT LOOK
LIKE IN INDIAN COUNTRY?

• Definition can range from intentional inflicted
  injury to
• any act that impairs the developmental
  potential of a child.
• Included in this definition are neglect (acts of
  omission) and physical, psychological, or sexual
  injury (acts of commission) by a parent or
  caregiver.
• Nationally, physical abuse (18.6 of reports)
  occurs more frequently than sexual abuse (9.6)
  but is not as often reported (DHHS, 2001).
• 
  continued
  . . .

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• American Indians/Alaska Natives compose 2 of
  reported victims (DHHS, 2001).
• Few statistics exist most are general
  statistics, few are Tribal or Reservation
  specific, not tracked the same by each site or
  organization
• In 1999, a National Indian Justice Center film
  Bitter Earth Child Sexual Abuse in Indian
  Country estimated that 1 in every 4 girls and 1
  in every 7 boys are victims by age 18.
• In 2002, the National Child Abuse and Neglect
  Data Systems (Department of Health and Human
  Services) reported victimization rates of 21.7
  cases per 1,000 children living in Indian
  Country (10.7 for Whites, 9.5 for Hispanics, 20.2
  for Blacks).
• 
  continued .
  . .

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In 2000, A Tribal survey done by the Casey
Family Programs Foundation for the Future
and the National Indian Child Welfare
Association estimated that in Indian
Country - That only 61 of child abuse
cases are reported - Over 80 of
responding Tribes had a Child Protection
Team (CPT) and protocols in place -
50 operated their own social and police
services - Only 23 of Tribes managed
their own cases - 33 relied on others
with no Tribal input - 2 contracted
for these services
continued . . .
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- Remaining 42 of Tribes worked with
individual states (20),
counties (11), Bureau of Indian
Affairs (7), and Tribal Consortiums (4).
- 42 of Tribes included IHS as a CPT
member but at the same time 77
claimed lack of access for
medical provider examinations
- 17.5 of Tribes used a local hospital
- 7 used a local doctor
- 3.5 used a specialist
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• PROJECT HISTORY
• Is a coordinated effort between Indian Health
  Service and Office for Victims of Crime to
  provide training and resources in the medical
  evaluation of child maltreatment to physicians,
  nurse practitioners, and physicians assistants
  who care for Native American/Alaskan Native
  children
• Evolved from a successful pilot project at the
  Ft. Duchesne Indian Health Center in Utah
  (Northern Ute Reservation)
• Began in 2000 and has to date received
  approximately 414,000 in operational funding
  from Office for Victims of Crime
• OVC funds expire 12/31/04 IHS Headquarters
  provided 286K for project operation for
  2005-2006
• Open to Tribal and IHS providers
• Same model of care used by the state of Utahs
• Childrens Advocacy Centers (also patterned
  after the
• Ft. Duchesne project)

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COURSE REQUIREMENTS

• Is a two year training commitment
• Prospective participants must submit with the
  application
• (beginning with the October 2003 class)
• - What hardware/software is available
  to them
• - Letter of intent to participate that
  includes a
• commitment to stay at their present
  position
• for the duration of the course
• - Letter of support for their
  participation from
• the facility director, immediate
  supervisor
• - CV and current license
• 
  continued . . .

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Year One - One week intensive
didactic/classroom training with
37.25-44.7 CMEs provided (November 2000, October
2003) - Needed hardware/software purchased
for each site for
photodocumentation of clinical findings and the
establishment of the telemedicine link for
consultation and peer review - One
week preceptorship with national expert faculty
of their choice (hands on clinical
and mentoring experience (35-42 CMEs
provided) - Participants conduct medical
examinations of child victims of abuse
with photodocumentation

continued . . .
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- Sites establish telemedicine link with base
(computers of participant and Project
Director are able to transfer data with
Second Opinion software) - All cases
conducted by participants with specific data sent
to Project Director for consultation,
peer review, teaching via software
provided - National expert consultation
available as determined by Project
Director

continued . . .
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Year Two - Participant photodocumentation
skills perfected - One week advanced
preceptorship with national expert
faculty of their choice (hands on clinical
experience with focus on case
interpretation as a consultant 35 CMEs
provided for physicians, 42 for nurses) -
All cases conducted by participants sent to
Project Director for consultation, peer
review, teaching via software provided
- Development and implementation of site
specific policies and procedures for
service

continued . . .
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- Participation in monthly Grand Rounds (peer
review, one CME provided) - Site
visit by Project Director - Certificate of
Excellence Award (plaque) upon successful
completion of both years of training -
Encouraged to be expert for local geographic
area - Encouraged to develop and/or
participate in the local MDT/CPT - Attend at
least one national child abuse conference with a
specific medical track on a yearly basis
- All IHS/OVC Child Abuse Project resources
still available to all those who have
successfully completed the course
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PROJECT GOALS

• (1) To provide equipment, training, and
  resources to medical providers within the
  Indian Health Service and Tribal programs on the
  medical evaluation of child maltreatment
• (2) To create a database of statistics on child
  abuse and neglect in Indian Country including
  Alaskan Natives
• (3) To create an infrastructure of experts in
  the field of child maltreatment within Indian
  Country including Alaskan Natives to locally
  serve child victims and their families
• (4) To create an ongoing system of resources in
  this field in Indian Country including Alaskan
  Natives for medical providers
• (5) To create a mechanism of peer review and
  quality improvement for services provided to
  Native child victims of maltreatment
  

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PROJECT PARTICIPANTS

• November 2000 Class
• - Alaska
• Bethel - Participant Jennifer
  DeLeon, MD
• - Status Completed
  2004 but leaving 11/04
• - Project purchased 35
  mm camera with flash to fit
• their colposcope,
  software, scanner
• Dillingham - Participant Jackie
  Tindall, FNP
• - Status
  Resigned position in 2001, no one
• designated to
  continue project
• - Project
  purchased software and scanner
• Kotzebue - Participant Janet
  Shackles, MD
• - Status Resigned
  position in 2001 Pam
• Grimaldi, MD,
  designated to continue
• - Project
  purchased software, colposcope
• and camera,
  scanner
• 
  continued .
  . .

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Juneau - Participant Mark Peterson, MD
(SEARHC) - Status
Completed 2004 -
Equipment/software at Child Advocacy Center
- Arizona Whiteriver - Participant
Janelle Brown, MD
- Status Completed 2004
- Project purchased colposcope with camera,
scanner,
software Tuba City - Mary Jo Parys,
FNP - Status Will
complete 2004 -
Project purchased colposcope with camera,
scanner, software
San Carlos - Participant Sharon Wattley, MD
- Status Resigned
position before year 1
preceptorship, no one designated to

continue project
- Project purchased colposcope with camera,
scanner, software,
modem

continued . . .
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Gila River - Participant Adelaide Bahr,
MD - Status
Decided not to participate as this was
not a priority for the
service unit -
Project purchased colposcope with camera,
scanner, software,
modem - New Mexico ACL Hospital
- Participant Nelly Wolff, MD
- Status Resigned position after
end of first
year, no one designated to continue project
- Project purchased
colposcope with camera,
scanner, software - Montana
Ft. Belknap - Participant Dennis
Callendar, MD -
Status After initial training, the service
unit decided
to refer all child abuse
cases to Great Falls
- Project purchased no
equipment for this site

continued . . .
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Ft. Peck - Participant Peggy OHara,
MD - Status Resigned
position shortly after initial
training site requested to send
another provider to
next course but they did not
- Project purchased colposcope and camera,
software
Crow Agency - Participant Lori Byron, MD
- Status Decided not
to continue after year 1
as she felt she already knew the
material -
Project purchased colposcope and camera,
teaching tube,
software Northern
Cheyenne - Sharon Plotke, MD, and Melissa

Broomhall, MD
- Status Both resigned within a

year Dave Freeman, FNP,
designated to
continue
- Project purchased colposcope
and
camera, software, scanner

continued . . .
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- Wyoming

Ft. Washakie - Jackie Nelson, MD
- Status Completed 2004
- Project purchased scanner
and software
SUMMARY

• 2000 Class Completed
• Bethel, Alaska
• Juneau, Alaska
• Whiteriver, Arizona
• Tuba City, Arizona
• Ft. Washakie, Wyoming
• Will receive plaque and new edition of software
  
• query and forensic form

• 2000 Class Still Participating
• Northern Cheyenne, Montana
• Kotzebue, Alaska

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October 2003 Class - Alaska
Bethel - Susanna Block, MD, and Amy
Strnad, MD - Status
Dr. Block has completed year 1 but is
resigning Dr. Strnad took the
summer off and the
site would not pay for year 1 preceptorship,
she may be leaving
also waiting to test
telemedicine connection
- Project purchased no new equipment since
2000 Kotzebue - Pam Grimaldi, DO
- Status
Completed year 1 but telemedicine
connection not functional
- Project
purchased no equipment since 2000
Juneau - Amy Dressel, MD
- Status Completed year 1
- Project purchased no equipment for
site funded CAC
by Catholic Community Services
telemedicine connection
functioning
continued . .
.

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- Montana Northern
Cheyenne - Dave Freeman, FNP
- Status Completed
year 1
- Project purchased no new equipment


since 2000, telemedicine connection
functional
- Oklahoma Clinton -
Dolly Garcia, MD -
Status Completed year 1, telemedicine
connection not functional
- Project
purchased video camera, software - North
Dakota Belcourt - Pam Kidd,
MD, and Kathleen Hughes-Kuda, MD
(gynecologist exam,
psychiatrist interview)
- Status Both completed year 1
- Project purchased
video camera, software
telemedicine connection
functioning

continued . . .

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- South Dakota Fort
Thompson - Renette Kroupa, PA-C
- Status Completed
year 1
- Project purchased no equipment for
this site
telemedicine connection
functional
Wagner - Gretchen Esplund, MD
- Status Not completed year 1 due to
staffing at her
site, telemedicine connection not functional
- Project purchased
video camera, software
telemedicine connection not functional
Sisseton - Lois Crawford, MD
- Status Completed year 1
- Project
purchased video camera, software
telemedicine
connection functioning




continued
. . .

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- Michigan Keweenaw
Bay - Teresa Frankovich, MD
- Status Completed year 1
-
Project purchased video camera, soft-
ware
telemedicine connection not
functional
Sault Ste. Marie - Vivica Fitzpatrick-Sherman,
MD -
Status Completed year 1, telemedicine
connection
not functional
- Project purchased video camera and

software - New Mexico
Shiprock - Karen Cook, FNP
- Status Completed year 1
- Project purchased digital
camera for existing
colposcope, software telemedicine
connection functioning




continued . . .

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Pine Hill -
Jean Proper, FNP -
Status Completed year 1
- Project purchased video camera,
software
telemedicine connection not functional
Gallup - John Ratmeyer, MD
- Status Completed year 1
- Project purchased video camera,
software
telemedicine connection not functional

• SUMMARY
• Participants who have dropped out of project to
  date
• Bethel Susanna Block, MD
• Amy Carson-Strnad, MD ?

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PARTNERSHIPS

• November 2000 Class Boise, Idaho
• - American Indian Information Network in
  Albuquerque
• provided all course materials, equipment
  rental, faculty
• travel/fees, transportation, food
  (35,000)
• - CARES Unit, St. Lukes Regional Medical
  Center, Boise,
• Idaho, provided staff, secretarial
  support, training facility
• (approximately 10,000)
• - Cultural component (Navajo) provided by
  Robbie
• Daniels, Gallup, New Mexico
• 
  continued . . .

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• October 2003 Class Oklahoma City, Oklahoma
• - Project Making Medicine (University of
  Oklahoma)
• provided all course materials, some
  student/faculty
• correspondence, travel/hotel for
  nonIHS students,
• training facility, transportation,
  food, coordination of
• activities, clerical support,
  speakers, other (25,000)
• - Cultural component (Cheyenne) provided
  by Project
• Making Medicine
• 2005 Class Month and date not yet determined
• - University of Utah perhaps
• - Cultural component (perhaps Ute,
  Paiute,
• Goshute, Shoshone, or other local
  Tribe)
• 
  

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PERMANENT EXPERT FACULTY

• P. Jane Powers APRN, BC, MS, FAANP (Project
  Director)
• Jay M. Whitworth, MD (Jacksonville, Florida)
• Robert W. Block, MD (University of Oklahoma)
• Astrid Heger, MD (Los Angeles County/University
  of Southern California Medical Center)
• Carolyn Levitt, MD (Midwest Regional Childrens
  Advocacy Center)
• Rich Kaplan, MD (Midwest Regional Childrens
  Advocacy Center)
• Joyce Adams, MD (University of California San
  Diego)
• Lori Frasier, MD (Primary Childrens Medical
  Center, Salt Lake City)
• Deborah Lowen, MD (University of Oklahoma)
• Renee Ornelas, MD (University of New Mexico)
• Sites for clinical preceptorship training.

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PROJECT EVALUATION

• Were program goals met?
• (1) To provide equipment, training, and
  resources
• (2) To create a database of child abuse
  statistics
• (3) To create an infrastructure of experts
  in Indian Country
• (4) To create an ongoing system of
  resources
• (5) To create a peer review/quality
  improvement mechanism
• Didactic (classroom) training evaluation
  (handout)
• Preceptorship evaluation
• Outcome evaluation via Site Specific Data,
  still in progress
• Site visits comments from MDT/CPT members,
  supervisor, participant

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PROJECT ACCOMPLISHMENTS

• The number, variety, caliber, and commitment of
  the national experts
• - No other existing child abuse program
  has this many of the
• nationally recognized experts on their
  faculty
• - These are the experts who are
  conducting the research in the
• current literature that guides current
  practice
• Commitment of participants
• National program publicity and recognition in
  Indian Country and the number of providers who
  want to participate
• The elevation and standardization of the quality
  of medical care provided to AI/AN child victims
  of abuse (best practices)
• The collection of case statistics for each
  participating site begins a national database for
  Indian Country
• 
  continued . . .

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• The collection of child abuse cases (photographs)
  from participating sites begins a one of a kind
  national library of such data
• Is an example of a successful partnership between
  two
• federal agencies for the improvement of
  care/services to
• AI/AN
• Project listserv in progress
• Web site http//www.ovccap.ihs.gov
• Whiteriver site already seeing child abuse case
  referrals from San Carlos, elsewhere
• Interest from a nonprofit organization in
  Bangkok, Thailand, in implementing same type of
  program in slums
• Program nominated for an award from APSAC (not
• successful)
• Letters sent through a private citizen for a
  congressional
• appropriation for funding
• Program Assistant hired August 2004

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PROJECT BUDGET

• SEE HANDOUTS

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PROBLEM AREAS

• Staffing levels most participating sites are
  short staffed on medical providers which has
  delayed project activity completion
• Tech support delayed, not a priority for the
  department
• - Has delayed telemedicine hookup, thus
  case review and
• participation in Grand Rounds
• Participant completion of case and site specific
  data forms
• Funding secured on a short term basis only, need
  long term ongoing funding request to federal
  agencies, congressional request
• Most significant problem is that IHS/Tribes have
  no uniform case tracking mechanism
• - Examples
• - Statistics from sites not reliable
• - What is the extent of child abuse in
  Indian Country?

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FUTURE PLANS

• Continued pursuit of more permanent, long term
  funding including partnership with University of
  Utah (private sector funding possibilities such
  as Robert Wood Johnson, other)
• Pursuit of additional funding for 2005-6 to
  increase number of participants, provision of
  equipment, full time assistant
• Computerized learning modules for didactic
  training
• - Problem is too much content/activities
  packed into 5 full days
• of classroom (didactic) training but all
  are important
• - Participants complete modules (lectures
  with quiz) at their
• own pace BEFORE scheduled didactic
  training
• - Summary/discussion of topics only at
  didactic training
• 
  
  continued . . .

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• To motivate support for the development and
  implementation of an IHS-wide (including BIA,
  FBI, Tribes) uniform child abuse case tracking
  mechanism for obtaining accurate and meaningful
  statistics (NICWA pilot project)
• Specific standardized IHS form for documenting
  the medical examination for suspected child abuse
  
• Utilization of real time software technology
  when needed
• (example Bethel)
• Merge programs for adult and child sexual assault
  into a single holistic approach victimization
  across the life span

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• END