Health Care

This section reviews—

• Anonymous evidence collection–NH.
• Anonymous reporting–ME.
• Billing system–MS.
• Health care screening–OH.
• Mental health professionals–OH.
• Program expansion–NY.
• Role of EMS–OH.
• Standard protocols–OH.

Anonymous Sexual Assault Medical/Forensic Examinations—New Hampshire

Overview
In 1989, the New Hampshire Attorney General's Office formed the Sexual Assault Protocol Committee, representing the medical, legal, law enforcement, victim advocacy, and forensic science communities, for the purpose of establishing a New Hampshire protocol and forensic exam kit. The committee made recommendations based on the physical and emotional needs of sexual assault victims, reasonably balanced with the basic requirements of the legal system.

In 1998, New Hampshire created a system of anonymous evidence collection. With the anonymous system, each kit is given a unique serial number. That serial number is used in place of a patient's identifiable information (e.g., name, date of birth) on all evidence collection kit forms, as well as on the outside of the kit. Completed kits are given to law enforcement after patients are discharged from examining hospitals, and law enforcement delivers the kits to the crime lab after creating case numbers and files.

The crime lab preserves evidence but does not analyze any portion of the evidence. Victims have 3 months to report the crime to law enforcement. If a report is not filed after 3 months, the crime lab sends the evidence back to the jurisdictionally appropriate law enforcement agency where the evidence is housed indefinitely or destroyed, depending on local policy. In 2005, the protocol and kit were updated through New Hampshire's multidisciplinary process. The window of anonymous evidence collection and maintenance was decreased to 60 days, based on findings that most victims make their decision to report within this period.

Goals

• Decrease the likelihood of a chain of custody breach by decreasing the amount of time evidence is stored at the hospital.
• Increase the probability of having biological evidence in cases in which victims initially choose not to report to law enforcement but later change their minds.
• Increase options available to victims.
  

Making the Idea a Reality
Creating the protocol was a relatively simple process with unanimous agreement by the New Hampshire Sexual Assault Nurse Examiner Advisory Board. Implementing the protocol was more challenging.

Learning is a fluid process. Multidisciplinary training of law enforcement, medical professionals, and crisis center advocates took place throughout the state on multiple occasions. Law enforcement personnel needed to be trained on the new protocol, as well as on their role in accepting and delivering the kits to the crime lab without seeking further information about the crime. Medical professionals and advocates needed to be trained on the new option that could be offered to victims.

Additionally, the committee, in conjunction with the Attorney General's Office, worked with prosecutors and chiefs of police so that the appropriate directives were given to officers in the field and at the police academy.

Benefits to Victims
The benefit to the victim is that time-sensitive evidence can be collected when it is still viable and can be preserved in a manner that will allow its use at some future date, should criminal prosecution be pursued. The importance of this option was impressed on the protocol committee in an anonymous case involving a patient who was twice assaulted by someone from a previous relationship. Because she was in a new relationship, she was undecided about reporting the first incident but did have anonymous collection of evidence. The second assault was reported and evidence from both kits was effectively used to plea bargain the case and to send the assailant to prison.

Benefits to Criminal Justice
Anonymous medical forensic evidence provides time-sensitive evidence collection when it is still available on the victim's body. The practice ensures that the evidence is preserved in a manner that will allow its later use if criminal prosecution is pursued, and it enables better corroboration of the crime at trial.

Lessons Learned

• Learning is a fluid process. It took about 2 years for law enforcement to accept anonymous reporting as a standard practice. Additionally, hospital staff needed to be trained on the process. Frequently, hospitals had offered victims younger than age 18 the option of anonymous evidence collection, which was in violation of the New Hampshire reporting laws.
• The statute of limitations in sexual assault cases should always be taken into consideration when creating an anonymous collection system. In New Hampshire, the statute of limitations for reporting a sexual assault where a criminal prosecution is still a possibility is 6 years from the time of the assault if the person is 18 years old or older. In actuality, the kits that are collected should be housed until the statute has run out before they are destroyed. The New Hampshire crime lab is not physically able to accommodate this request, so many kits are routinely stored in evidence rooms at law enforcement agencies.

Contact Information
Extensive contact information for victim/witness assistance programs, sexual assault crisis centers, elder services, and more is included in the following publication:

State of New Hampshire, Office of the Attorney General, An Acute Care Protocol for Medical/Forensic Evaluation, Fifth Edition, 2008, Cornish, New Hampshire.

Anonymous Reporting Legislation—Maine

Overview
The purpose of this legislation is to allow sexual assault victims to receive reimbursement from the Maine Victims' Compensation Fund for sexual assault forensic exams without having to report to law enforcement. In these cases, the fund must be used before insurance benefits are used.

Goals
To enable victims to receive sexual assault medical forensic examinations without cost, regardless of whether they report assaults to law enforcement.

Making the Idea a Reality
This legislation was part of a larger bill that created the first standardized forensic kit in Maine. The legislation resulted from a legislative study requested by the Maine Coalition Against Sexual Assault (MECASA), which examined a range of issues related to forensic exams. (Because most stakeholders had seats at the table, the coalition was able to clarify the legislation's language well before it was brought to the legislature. Participating parties expressed their continued support for the bill throughout the process.)

Benefits to Victims
Victims can take time to decide if they want to report or not, while ensuring that the evidence is available should they need it. Victims do not need to worry about who will pay for the exam or about being billed by their insurance for it.

Benefits to Victim Service Professionals
Victim service professionals can tend to victim needs without requiring them to decide whether to report to law enforcement.

Evaluation Efforts
A full evaluation of the program has not yet been completed, but reimbursements for kits through the Victims' Compensation Fund have increased.

Lessons Learned
As with most major legislation, compromises had to be made along the way. The legislation had two shortcomings. First, as a result of concerns raised by law enforcement about storage of the kits, agencies are required to store kits for a minimum of 90 days (though many store them longer). Ideally, MECASA would like to see the storage run in line with the statutes of limitation. Second, while there is no reporting requirement for a medical forensic examination including sexually transmitted infection and pregnancy prophylaxis, victims must report crimes if they wish to receive compensation from the fund for other covered expenses.

In the last legislative session, the coalition considered a related issue: how to address individuals who come into the emergency department unconscious, but with significant indications that they have been sexually assaulted.

Contact Information
Maine Coalition Against Sexual Assault
83 Western Avenue, Suite 2
Augusta, ME 04330
207–626–0034
info@mecasa.org

Uniform Billing System for Forensic Exam Payments—Mississippi

Overview
Legislation was passed in July 2005 to create a uniform system of payment based on the existing Victim Compensation Program. The new system's rules and regulations require hospitals to submit a universal billing form and a completed sexual assault evidence kit form, with correct coding within a series of recommended codes.

Goals
The goal of standardized billings for forensic medical exams is to ensure that charges are submitted accurately and fairly statewide.

Making the Idea a Reality
In 1998, a committee of prosecutors, criminologists, advocates, medical professionals, and law enforcement officers convened to create a statewide evidence kit that would meet the needs of the state crime lab and provide statewide uniformity.

As the number of SANE services increased, more evidentiary exams were being billed to the counties as required by state law. The individual county boards of supervisors were incurring large bills with no source of revenue. Payment was processed differently by every county. Billed charges were generally processed without thought for accuracy or fairness. The amounts that hospitals were paid varied widely, and some hospitals received no payment.

To offset the inconsistencies, a multidisciplinary statewide SART committee reviewed and completely updated documentation forms in the evidence kit to reflect the U.S. Department of Justice's National Protocol, the International Association of Forensic Nurses' Standards of Practice, and best practices described in the medical, forensic, and criminal justice literature. The new forms were sent to all hospitals, SANE programs, and law enforcement agencies and were posted online for download.

As part of the new payment system, a SANE was hired by the Victim Compensation Program to review every evidence kit and billing form. After review, the data is sent monthly to the SANE program administrator, who provides feedback, consultation, and training to hospitals and SANEs throughout the state. The overall program data is organized and used to provide raw material for research and to pinpoint lack of resources and areas of need.

The initial evidentiary exam and medical care can be billed for amounts up to $1,000. This fee is intended to cover basic medical care, evidentiary procedures, initial sexually transmitted disease and HIV prophylaxis, and pregnancy screening and prevention. Other services are paid as medically necessary when filed under the victim compensation guidelines.

In 2006, a series of regional trainings were held for hospital billers and coders and medical staff in clinical settings.

Lessons Learned
The system is not perfect. Some hospitals are choosing to go unpaid rather than train their staff, and personnel have complained that the form is overly long and involved. The evidence collection kit committee agrees that the form is long, but notes that it includes elements essential to the care and documentation of complex cases.

The Mississippi system is off to a good start. The form is well accepted by SANEs. Physicians and nurses with no specialized forensic training have stated that the form guided their exam and documentation in a helpful way. Some hospitals are setting aside part of the billing proceeds into a SANE fund that pays for continuing education, call time, and the certification exam for their SANEs.

Currently, the billing system assigns usual and customary charges to each CPT (current procedural terminology) code. Ways to automate the system are being explored.

The expertise of a biostatistician is needed to develop a data management system for organizing information and creating data applications. The program is actively searching for grant funds for this technical innovation.

It is helpful to include many different types of professionals in the planning stage to look at billing solutions from many angles. Frontline users must be involved from the beginning. Mississippi also learned that—

• Persons involved in the planning must be at a level of authority to implement the group's decisions.
• Anything important is worth a long-term commitment to the change process.
• Money is a powerful motivation for change. All proposals should have a financial impact statement or business plan. Good intentions are not enough. The potential for profit makes a project attractive.
• It is important to keep research capability in mind when building systems of care.
• Consult with experts.

Contact Information
Mississippi Coalition against Sexual Assault
P.O. Box 4172
Jackson, MS 39296
601–948–0555

Health Care Screening for Intimate Partner Violence—Ohio

Overview
The Ohio Department of Health (ODH) partners with the Ohio Domestic Violence Network (ODVN) to train health care agencies in how to screen patients for intimate partner violence.

Goals
The goals are (1) to identify victims of intimate partner violence during routine health care delivery and (2) to encourage appropriate responses and referrals when patients disclose intimate partner violence to health care professionals.

Making the Idea a Reality
ODH and ODVN staff worked together with other health care partners to develop the curricula, make contact with training sites, and implement and publicize the trainings.

Benefits to Victims
Victims are more likely to receive timely and appropriate responses and better referrals from health care professionals.

Benefits to Criminal Justice
Increased support to victims leads to better success when the criminal justice system becomes involved.

Lessons Learned
Public and private sectors need to work together to provide training to a greater number and variety of organizations. The work also builds relationships and increases cooperation among programs, leading to other projects.

Contact Information
Ohio Department of Health
246 North High Street
Columbus, OH 43215

Core Competencies for Mental Health Professionals—Ohio

Overview
Core competencies for mental health professionals are intended to provide minimum expectations for all mental health professionals regardless of their areas of specialization.

Goals
To create a minimum standard of knowledge that all mental health professionals should receive in their basic training and continue to achieve throughout their careers, plus all future levels of knowledge set as the standard.

Making the Idea a Reality
The Ohio Department of Health worked for more than a year with representatives from mental health agencies and commissions in Ohio, sexual assault and domestic violence professionals, and other service providers to create the core competencies. These competencies are intended as a prerequisite for all generalist practitioners and are used to identify training needs. Individuals may seek additional training and specialize in sexual assault and domestic violence.

The competencies include—

• Ethical and legal considerations.
• Identification and assessment of sexual assault and intimate partner violence.
• Knowledge and proficiency for intervention.
• Knowledge and proficiency for prevention and awareness.

Benefits to Victims
The Mental Health Competencies are designed to improve mental health services for victims.

Benefits
Core competencies for mental health professionals have an indirect benefit to criminal justice. Core competencies could potentially decrease the likelihood for revictimization by giving mental health professionals skills that can decrease trauma to victims.

Lessons Learned
This is a large and ongoing project. Project staff find that the core competencies also apply to other health care providers and even rape crisis centers themselves. However, much work remains to be done to integrate rape crisis and mental health services.

Contact Information
Ohio Department of Health
246 North High Street
Columbus, OH 43215

Expansion of Sexual Assault Examiner Programs—New York

Overview
New York's Sexual Assault Examiner (SAE) programs were established in 1995 to improve the delivery of emergency care to sexual assault victims.

SAE programs operate in metropolitan, suburban, and rural communities throughout New York State. Each program follows basic protocols, but also incorporates unique elements as needed by its service area. SAE programs may offer training to ancillary medical staff who have contact with victims, conduct public speaking and outreach activities, and train law enforcement and prosecutorial staff.

Most of New York's SAE programs are supported by federal STOP Violence Against Women Act funds, which are administered by the Division of Criminal Justice Services' Violence Against Women Unit.

Goals
New York's SAE program has four goals. The first and foremost is to restore the health and well-being of sexual assault victims by treating their physical and psychological trauma. The second is to develop a team of specially trained health care professionals to perform forensic exams and provide aftercare. Third, SAE programs seek to develop specialized training for future sexual assault forensic examiners. Finally, the program seeks to improve crime reporting and conviction rates for sexual assault through collaboration with law enforcement and prosecutors.

These programs have established procedures for standard and comprehensive care for all sexual assault victims and have examiners who are specifically trained to care for these victims. When victims sustain serious injuries, forensic examiners ensure that their medical needs are met first. Examiners are trained to provide a sensitive examination and collect forensic evidence as components of the overall treatment process. They are usually available to victims within 60 minutes of their admission into hospital facilities.

Private areas are dedicated for victim treatment within emergency rooms and may include separate waiting areas, exam rooms, showers, phones, and forensic equipment. Some programs also provide a change of clothing for victims.

Another essential element of SAE programs is collaboration with other agencies. These programs work with law enforcement personnel, prosecutors, emergency medical services, community organizations, and volunteers to integrate service providers under the umbrella of the SAE. This collaboration recognizes sexual assault as a serious crime that requires immediate attention.

Sexual Offense Evidence Collection Kits and Drug Facilitated Sexual Assault Kit
The Division of Criminal Justice Services (DCJS) provides Sexual Offense Evidence Collection Kits free of charge to all hospitals in New York State. In November 2003, DCJS released a standardized Drug Facilitated Sexual Assault Kit, as was requested by various disciplines, to be used when service providers suspect that drugs were used to facilitate the assault. The division worked very closely with the Forensic Services Unit in DCJS, the New York Prosecutors Training Institute, state and local laboratory personnel, individual prosecutors, several sexual assault nurse examiners, and other individuals to ensure that this kit meets standards that all disciplines require. The kit includes two grey-topped blood tubes and a urine container for collection of specimens. It also contains instructions for use, a laboratory information form, and a consent form for authorization of release.

Making the Idea a Reality
The goal of DCJS's expansion effort was to ensure that the counties with the highest reported rape statistics had at least one SAE program. As DCJS looked at the top 20 counties, the division found that it was already funding programs in 14 of those counties. The state's Department of Health identified hospitals in the remaining six counties that would be administratively and financially capable of supporting a program and then offered those hospitals funding to initiate a program. This effort led to the successful SAE program development in19 of the 20 counties. The one remaining county was interested as well, but was undergoing a renovation of its emergency room and a change in administration at the time. DCJS then looked at the next five counties with the highest reported rapes and helped establish two more programs.

Benefits to Victims
Victims benefit from prompt, compassionate medical care and proper forensic evidence collection. A victim of sexual assault can go to any hospital in New York State and receive a rape exam, including the collection of forensic evidence. The victim has 30 days to decide whether  she or he wants to turn the kit over to law enforcement. The hospital must maintain the kit for 30 days, but if room is available, most hospitals in New York will keep them much longer.

DCJS has found that most victims who receive an exam from a trained sexual assault examiner (as opposed to an emergency room physician) are more likely to turn their evidence collection kit over to law enforcement for pursuit of a criminal case.

Benefits to Victim Service Professionals
Laboratories report that the evidence collected by trained SAEs is generally better than evidence collected by emergency room physicians. Also, most prosecutors believe that victims are more willing to pursue a criminal justice case if their exam was conducted by a trained SAE.

Evaluation Efforts
In June 2002, DCJS conducted a survey of Sexual Assault Examiner Programs. Note that protocols have since been updated. For example, the survey references blood tubes in the exam kits, but New York now uses buccal swabs for DNA collection. [See SANE Prosecution Survey (Word) in this toolkit.]

Research indicated that prosecutors view SAE programs as a valuable resource in achieving successful outcomes in sexual assault cases. Many prosecutors surveyed believe that the involvement of a SAE in a sexual assault case makes it more likely that the victim will remain committed to prosecution, which they credit to the compassionate care and support shown by SAEs. In addition, laboratory personnel report that evidence collected by trained SAEs is very often superior to that collected by non-trained SAEs. Outcomes from this survey led to the expansion of SAE programs in New York.

Lessons Learned
Hospitals do not make a profit from SAE programs. In fact, they are more likely to lose money. That fact makes it difficult to explain to hospital CEOs what a SAE program is and why they should have one. Some hospitals refused to host such a program. Others viewed it as an opportunity to provide services for victims of crime, as well as to provide a great community service. It is very important to have the hospital completely buy in to these programs. Without this commitment, any SAE program has a huge potential for failure.

Contact Information
New York State Division of Criminal Justice Services
4 Tower Place, 10th Floor
Albany, New York 12203–3764
800–262–3257
InfoDCJS@dcjs.state.ny.us

Role of Emergency Medical Services on Sexual Assault Response Teams—Ohio

Overview
Emergency medical services (EMS) personnel provide SARTs with medical information related to emergency procedures in response to sexual assaults and should be included as core members of Sexual Assault Response Teams. EMS practitioners on the team—

• Give detailed explanations of EMS procedures and protocols.
• Address issues regarding scene preservation practices.
• Assist the team with general crime scene preservation practices.
• Act as liaison between the team and the EMS community.
• Provide testimony in court.

Goals

• To involve EMS representatives in the SART.
• To educate all the area's EMS providers on the proper assessment and treatment of sexual assault patients and the importance of transporting patients to a hospital with a SANE program.
• To teach all the area's EMS providers how to properly document a run sheet that can be admissible in court.

Making the Idea a Reality

• Determine what type of EMS system is in your area.
• Contact management at the service centers and explain the SART/SANE model.
• Ask each service provider to send a representative to the next SART meeting.
• Contact the training officers at each service center or at the Medical Command Hospital (depending on the system) to set up a lecture on the proper assessment and treatment of sexual assault patients and the importance of transporting victims to a hospital with a SANE program.
• Set up lectures at schools offering EMT-basic/paramedic training on how to assess and treat sexual assault patients and on the importance of transporting them to a hospital with a SANE program.

Benefits to Victims

• Patients are transported to hospitals with SANE programs and receive superior services and care.
• EMS assists with the preservation of evidence.
• EMS informs patients of their options regarding advocacy and facilitates the dispatching of advocates at the hospital.
• Patients generally have a more positive experience with EMS personnel, who have been trained in how to talk to individuals who have been sexually assaulted (e.g., remaining objective, building rapport).

Benefits to Victim Service Professionals

• EMS and the police departments are on the same page when it comes to transporting an individual who has been sexually assaulted. When it comes to transporting a patient, there may be a conflict in the police department's standard operating procedure and the paramedic's protocols.
• EMS personnel are able to preserve evidence while performing patient care.
• EMS personnel may be the first health care providers with whom an individual who has been sexually assaulted interacts. Their attitude and demeanor can affect how a patient cooperates during the rape exam and with law enforcement.
• EMS personnel are able to provide testimony in court as to the victim's initial appearance and demeanor, injuries, and so forth.

Evaluation Efforts

• Evaluations of the training provided to EMS personnel by SART members are completed at the end of each course of training to assess the learning needs of EMS personnel.

Lessons Learned

• EMS personnel may need continuing education on the proper assessment and treatment of sexual assault patients and the importance of transporting them to a hospital with a SANE program. Every 2 years would be beneficial.
• EMS personnel must be reminded that they are there to provide patient care and not to step outside their role and attempt to act as a representative of law enforcement. There is usually no need to conduct detailed questioning about the sexual assault.
• Documentation is historically a "problem area" for EMS and needs attention coupled with proper training.

Contact Information
Cleveland Emergency Medical Service
Sergeant Chris Chumita
1701 Lakeside Avenue
Cleveland, Ohio 44114
216–664–2020, ext. 250

Cleveland Rape Crisis Center
Lindsay Fello-Sharpe, MSSA, LSW
Cuyahoga County Sexual Assault Response Team Manager
1370 Ontario Street, Suite 420
Cleveland, OH 44113
216–619–6194, ext. 117

Standardized Protocol for Medical Forensic Exams—Ohio

Overview
The Protocol for the Treatment of Adult and Adolescent Sexual Assault Patients was created to guide practitioners to provide comprehensive, standardized, equitable treatment to sexual assault victims.

Goals
To ensure that all victims of sexual assault receive the best possible care in the emergency department and that evidence is collected correctly.

Making the Idea a Reality
An interdisciplinary group wrote and continues to update the protocol. Additionally, the group collaborates to implement trainings in the protocol throughout Ohio.

Triage guidelines in a hospital setting

• Patient should be seen by a health care provider within 15 minutes of arrival, or as soon as possible thereafter.
• Patient should be given priority for room assignment in a private area.
• Regardless of whether the patient chooses to proceed with legal prosecution or to talk with law enforcement personnel, health care providers need to provide swift and immediate medical care to the patient.
• A hospital/facility is obligated under Ohio law to report sexual assaults, but the law does not require that patients' names be given. If patients decide not to report, the hospital/facility gives law enforcement dates and general locations of assaults without giving patients' names, addresses, or other identifying information.
• Medical personnel need to inform patients of their rights about whether or not to speak to law enforcement personnel.
• Rape crisis advocates are contacted at the same time physicians or SANEs are called and should be present when advocate support is offered to patients.
• To ensure that patients feel safe about saying who they would like present during procedures, medical personnel should ask everyone accompanying patients to leave the room prior to examination. At this time, patients should again be consulted as to whom, if anyone, they would like as onsite support.
• SART team members' roles need to be decided prior to a patient's arrival. If disagreement arises between service providers and/or with support persons, discussions must take place at a later time or away from patients.
• Speaking to law enforcement can never be a precondition to the collection of evidence. Most communities in Ohio do not conduct joint interviews, but even if community protocols call for joint interviews, patients must always have the right to make final decisions about who is present during medical interviews and evidence collection.

Benefits to Victims
Victims receive consistent quality of care.

Benefits to Victim Service Professionals
Evidence is collected and managed correctly.

Lessons Learned
Changes occur frequently in the protocol and new areas continually need to be addressed. Service providers are now asked to check the Ohio Department of Health's Web site regularly to ensure that they use the most recent version of the protocol.

Contact Information
Ohio Department of Health
246 North High Street
Columbus, OH 43215

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