Violence Intervention Programme
Achieving Change: evolution of a multiagency response to child protection and family violence Australasian Conference Child Abuse and Neglect Sunday 29 March 2015; Auckland Child centred Child centred Reduce family violence: partner abuse and child abuse & neglect Child centred Violence Intervention Programme Shaken Baby Prevention Programme Reduce family violence: partner abuse and child abuse & neglect National Child Protection Alert System Violence Intervention Programme Maternity Care Wellbeing Child & Child centred Protection Shaken Baby Prevention Programme Reduce family violence: partner abuse and child abuse & neglect Gateway Assessment National Child Protection Alert System Violence Intervention Programme Maternity Care Wellbeing Child & Child centred Protection Shaken Baby Prevention Programme Reduce family violence: partner abuse and child abuse & neglect Violence Intervention Programme Miranda Ritchie, National VIP Manager for DHBs, Health Networks Ltd Helen Fraser, Violence Issues Lead, Ministry of Health Dr Catherine Topham, National VIP Trainer, Shine Professor Jane Koziol-McLain, Auckland University of Technology Acknowledgements • Jo Elvidge & Sue Zimmerman, Ministry of Health • Dr Russell Wills, HBDHB team and HB community agencies • Dr Patrick Kelly, Auckland District Health Board • Mollie Wilson & Anne-Marie Tupp, Health Networks Ltd • Chris McLean, Auckland University of Technology • Assoc. Professor Janet Fanslow, University of Auckland Health sector response timeline (2000-present) 2000-2 MoH NZ Health Strategy: FV specified as priority area Multi-ministerial inquiry Family violence Intervention Guidelines; Child and Partner abuse launched Train the trainers for DHB in FVI Four DHB pilot sites; Auckland, Counties Manukau, Lakes and Hawke’s Bay 2003-6 2007-2010 Nearly all DHBs establish VIP coordinator National evaluation results: significant gains DHB systems model emerged July: MoH launch FV resources developed including; posters; cue cards; flow charts; pamphlets; National VIP Coordinator; National VIP trainer; National VIP Coordinator meetings MOH fund DHB VIP coordinator roles (1.0 FTE) National evaluation assessing hospital responsiveness to FV commenced; incremental increases noted National resources include: website; National VIP Manager; National VIP Trainer; National VIP Evaluation; National VIP Whanau ora Advisor Whanau ora funding for DHB Satellite day with PSNZ Child Protection SIG VIP in primary care project 2011 National evaluation results ; 89% DHB score >70 for PA and CAN MoH funding for DHB VIP Coordinator continues VIP HIIRC site established Quality Improvement activity toolkit finalised MOU with CYF and Police signed by 20 DHB 2012/15 DHB evaluation by site or self audit Children’s Action Plan Child Protection Alert System Shaken Baby Prevention Project Vulnerable Children's Bill Vulnerable Children's Act 2014 Maternity Care, Wellbeing and Child Protection Gateway Assessments VISION The health sector is capable of providing early intervention to persons experiencing FV. The health sector routinely implement FV into practice. VIPs are consistent and sustainable. NZ families are free from violence. Monitoring and evaluation National evaluation of DHB, Quality Improvement Activity resource kit VIP training contracts Technical advice & national meetings National VIP Manager for DHB, National Network VIP Coordinator meetings Funded VIP coordinators in DHB Family Violence Intervention Guidelines Resources MoH Family Violence website, HIIRC website, posters, cue cards, pamphlets National VIP Systems Monitoring, audit & evaluation Staff training core, in-service and refresher VIP Coordinator Service reorientation Clinical Champions Senior management support & community collaboration DHB VIP Policies, standardised documentation peer-support Resources Posters, cue cards, pamphlets Clinical audit & feedback (QIA) Staff training core, in-service and refresher Clinical Leadership Charge Nurse Manager, Clinical head of Department, Nurse Educator, Nurse Practitioner VIP in services Policy and procedures Department assessment forms Standardised documentation Peer-support Resources Clinical Champions Service reorientation Posters, cue cards, pamphlets Evaluation slides • Modified ‘Delphi’ tool (AHRQ) for social and cultural context of • Aotearoa/NZ • Partner Abuse • Child Abuse and Neglect (revision in 2007) • 9 domains • Domain weightings • Overall and domain scores from 0 – 100 • Target score of 70 District Health Board site visits transition to self-audit Policies and Procedures • policies and procedures for assessment and treatment of victims; mandate identification and training; and direct sustainability Safety and Security • children and young people are assessed for safety, safety risks are identified and security plans implemented Physical Environment • posters and brochures let patients and vistors know it is OK to talk about and seek help for family violence Institutional Culture • family violence is recognised as an important issue for the health organisation Training of Providers • staff receive core and refresher training to identify and respond to family violence based on a training plan Documentation • standardised family violence documentation forms are available Intervention Services Evaluation Activities Collaboration • checklists guide intervention and access to advocacy services • activities monitor programme efficiency and whether goals are achieved • internal and external collaborators are involved across programme processes Delphi Median DHB Child Abuse & Neglect Scores 100 75 80 60 40 51 81 87 91 92 93 59 37 20 0 2004 2005 2007 2008 2009 2011 2012 2013 2014 Funding QI toolkit Whānau ora Delphi Median DHB Partner Abuse Scores 100 84 80 67 60 92 92 2013 2014 74 49 40 20 91 28 20 0 2004 2005 2007 2008 Abuse 2009Programmes 2011 2012 Partner Funding QI toolkit Whānau ora Programme Management Principles (according to MSP) • Remaining aligned to corporate strategy • Leading change • Envisioning and communicating a better future • Focussing on the benefits and threats to them • Adding value • Designing and delivering coherent capability • Learning from experience •Children’s Action Plan •Interagency collaboration; MOU •Integration of PA and CAN intervention •Strangulation guidelines, documentation & patient information, NCPAS, MCWCP •Vision that VIP will be BAU •Quality improvement activities; national and local level •National programme’s multifaceted approach i.e. standards/resources and technical advice ensure standardisation •VIP informed by clinical experience and focus ensures resources are real and useful •Train last •QI and real world experience inform programme planning and implementation Quotes from health professionals…. “I feel like I now have the tools to respond” ED nurse “If I can make a difference for one woman then it is worth it” “Its just become part of my practice” SCBU nurse ED nurse Quotes from patients accessing services …. “This is really great, asking the questions about family violence. I’m lucky it’s not a problem, but it’s a good message to talk about.” “No, not now …… but I wish someone had asked me 20 years ago” “Just before I left the hospital, the midwives informed me about family safety including "family abuse or violence". They [were] concerned I might need help as it happened to me before and I had newborn when I left. I just want[ed] to know who I can talk to if I need someone to share [contact] about my circumstance.” Preventing Shaken Baby Syndrome in New Zealand Kati Wilson National Co-ordinator for Shaken Baby Prevention Shaken Baby Syndrome • Leading cause of head injury in children under two years • Shaking is violent and often repetitive • Of the infants admitted to hospital: • One in five die • Most survivors have permanent brain injury • Many have other injuries. Economic cost of ‘shaken baby syndrome’ - million dollars per child 7% 10% Corrections for offenders* ACC modelled lifetime payments Complex needs group special education 83% "I would never hit my baby but he had to stop crying, so I shook him.” Adamsbaum C, Grabar S, Mejean N, Rey-Salmon C. (2010). Abusive Head Trauma: Judicial Admissions Highlight Violent and Repetitive Shaking, Pediatrics (126) 546-555 Dias hypothesis • Knowledge • Most people know that violent infant shaking is bad • There is a momentary loss of control • People who shake babies • Most are parents, and many are male • Face to face education soon after birth makes a difference • Both parents are present • There is a focus on the child • Reality is about to strike • Parents can spread the message PURPLE Peak pattern Unpredictable Resistant to soothing Pain like face Long bouts Evenings NZ Programme • One brochure • Six key messages • DVD • Posters • Educators guide Shaken Baby Prevention in NZ • Pilot Programme • Funded by the Ministry of Social Development • Mid term evaluation • Development of the national materials • National Programme • • • • • • Funded by The Starship Foundation for 6/12 Currently funded by the Ministry of Health National Advisory Group ACC Evaluation 15/20 DHB, 2 more by June 2015 250 000 pamphlets Systems approach Shaken Baby Prevention Management Support Clinical Policy Education: Yes No Declined DVD: Yes No Declined Signed & designation: Standardised documentation process Patient and staff resources Training Process for audit/evaluation Date: Northland DHB Six key messages 1. Crying is how babies communicate - this can be very frustrating. 2. It’s okay to walk away. 3. Never, ever shake a baby. 4. Never leave baby with anyone who might lose control. 5. Share this information with everyone. 6. If you think baby’s hurt, seek medical help at once. Resources www.powertoprotect.net.nz www.kidshealth.org.nz (coping with a crying baby) www.learnonline.health.nz www.youtube.com (coping with a crying baby) [email protected] “you realise you don’t have to push through, walk away, ask for help” Maternal Care, Wellbeing and Child Protection Multi-agency Group Julie Arthur, Midwifery Director, Hawke's Bay District Health Board Jenny Humphries, Midwifery Director Southern DHB Maternal Care, Wellbeing and Child Protection Multiagency Group Background: Many groups working to similar goal Some interaction in activities but no real interrelatedness Communication between various activity streams not always occurring or resulting in misunderstanding Belief that we could be doing things better Background (cont): Group purpose • Develop a generic set of principles to guide practice of professionals providing maternal care when child wellbeing and protection concerns are identified • Support and promote integration of services for women and babies with wellbeing, care and protection issues • Promote the principles of Whanau ora • Early identification with a preventative and supportive focus Membership Membership • • • • • • • • • • • • • • • • New Zealand College of Midwives Children’s Commissioner Paediatrician DHB Midwifery Leaders Maori Midwifery Advisor and LMC midwife Maori Researcher DHB Child Protection Coordinators Charge Nurse Manager Neonatal Care Social Work Leader Ministry of Health Office of the Chief Social Worker CYF Royal NZ Plunket Society Whanau ora advisors National VIP Manger RANZCOG Obstetrician and Gynaecologist NZ Police Core Practice Principles: Shared responsibility for protecting children Inclusive practice Information sharing/principle of relevance Interagency collaboration and cooperation Progress to date Literature review undertaken Acknowledgment that some DHB’s have existing processes Survey and agreement that a resource kit would be valuable to: support DHB facilitate a multiagency process build on the successes and share with others Working group developed kit Brief pilot… balance desire to test with demands for the resource Learnings from pilot sites • Challenge to integrate the resource kit into existing processes • Potential for previous processes to be re-examined and reviewed • Risk of over scrutinising • Impact of the privacy concerns that have recently become more prevalent • Challenge to get all involved informed of the changes • Commitment of administration time to change to new resources and then on-going requirements … then launch • The kit contains: • • • • • • • • • Introduction Memorandum of Understanding Terms of Reference and flowchart Referral form Letter to other health professionals involved Information sheet Meeting documentation e.g. agenda and minute templates Care plan documents Discharge forms Memorandum of Understanding Details shared purpose Signed by organisations who have representatives on the core consultation group Related document: Interagency Information sharing Guideline (2014) Maternity Care, Wellbeing and Child Protection Multiagency Forum process of operation Referrer sends MCWCP MAF referral form through to MCWCP MAF Coordinator/facilitator Coordinator/facilitator MCWCP MAF reviews Information Italics denote documentation templates available within MCWCP resource kit Coordinator/facilitator MCWCP MAF confirms receipt of referral to referrer Invitation to identified key worker/agencies sent to LMC, referrer and or key providers MCWCP MAF agenda drawn up Invitation and information to core MAF membership distributed at least 4 days/1 week prior to MCWCP MAF meeting Preparation by referrer & key worker/agencies prior to scheduled meeting. Preparation by LMC, referrer and key providers prior to scheduled meeting Vulnerable Pregnant Women’s MDT held Outcomes identified, supports/tasks allocated for follow up; Documentation includes: 1. meeting minutes that record actions, timeframe and responsibility 2. Individual case plans for maternity record 3. Other documents as indicated, e.g. MASP On-going MAF input required? No Yes Next meeting - Report back to MCWCP MAF, outcomes of allocated tasks Yes On-going MAF input required? No Close MAF involvement; complete MCWCP MAF discharge form and ensure referral to well child provider has been made (if not referred within previous actions) refer Meetings minutes will be sent out within one week or within four days of the next meeting (select one depending on meeting frequency) to enable action points to be completed by the next meeting The MAF care plan will be filed on the woman’s clinical record/ maternity care record The most appropriate professional involved in the woman’s care, e.g. LMC will discuss with the woman any plans developed with the MAF What next? • Internet based secure location accessed by key personnel •Time • National roll out of the tool kit for all DHBs • Coordination and Leadership of MCWCP • ? Extending remit of group up to 2 years of age • Roles and responsibilities in relation to Vulnerable Children’s Act • Roles and responsibilities in response to Children’s Team National Child Protection Alert System: A common sense approach to sharing health information Dr Patrick Kelly, Clinical Director, Te Puaruruhau, Auckland DHB Dr Russell Wills, Children’s Commissioner, Community Pediatrician, Hawke’s Bay DHB Miranda Ritchie, National VIP Manager for DHBs, Health Networks Ltd Acknowledgements • • • • • Dr Zoe McLaren, Senior Medical Advisor, Paediatric Society of New Zealand Dr Jeanine Nunn, Senior Medical Advisor, Paediatric Society of New Zealand Helen Fraser, Violence Issues Lead, Ministry of Health Sue Zimmerman, Violence Issues Lead, Ministry of Health DHB Child Protection Leaders/Teams Rationale • Child abuse and neglect are health events they are frequently not single events • Health providers often miss these events at presentation at re-presentation • Children at risk often have multiple health providers families are often mobile children often have transient placements within families movements frequently cross multiple DHB boundaries • Poor information sharing is a factor in bad outcomes the problem is not unique to child protection • New Zealand has an established medical warning system (NMWS); only system that links all health boards Child protection alerts • Are legitimately placed on the NMWS • Require a high degree of quality control a standard national threshold - referral to Child, Youth and Family a standard national process - decision made by a multi-disciplinary team a standard national quality of information available a conscious commitment to this from each DHB • Do not create a “child protection register” not another repository of personal information merely point to health information that already exists 2000 Systems review report (2000) findings; need greater information sharing 2003 Systems review report (2003) findings; need greater information sharing Health Boards develop own child protection systems 2004 T I M E L I N E HBDHB meet with Privacy Commissioner HBDHB Health Board begin loading CP Alerts on MWS Dr McLaren’s survey of health board CPAS 2005 CPAS profiled at PSNZ conference (HBDHB & ADHB) 2006 PSNZ CPAS position paper posted for consultation 2007 PSNZ Annual General Meeting ratify, in principle, CPAS position paper 2008 CPAS working group formed on PSNZ CP SIG mandate More than 10 years in the making! It takes time Children’s Commissioner endorsed, in principle, the CPAS Privacy Commissioner endorsed, in principle, the CPAS Chair of CP SIG advises CYF and the Police of the CPAS 2009 Auckland DHB begin Loading CPAS on MWS 2010 Ministry of Health endorse, in principle, the use of MWS for CPAS Finalised resource kit. Consultation with CYF. Meeting with S,I & A Directorate MoH. Meeting with DHB COO. NHB Business Unit accept governance of NMWS. Privacy Impact Assessment. Development of MOA with PSNZ and NHB BU. 2011 MOA finalised 2012 4 DHB approved; 9 MOA signed; & applications in progress Included in Better Public Service Plan 4 DHB approved (8 in total): 20 MOA signed and applications in progress Included in Minister of Health’s Statement of Intent 2013-2016: 12 DHB approved by June 14 8 DHB approved (16 in total); 4 DHB initiated planning 2013 2014 Criteria and placement Criteria • Any child up to 17 years of age where child abuse is suspected and/or confirmed (or the mother when concerns identified during antenatal period) • A referral is made to CYF by the DHB • A CPAS MDT review and approve the alert Placement • The alert is placed electronically with an option to have a paper alert within files • The alert reads as: CHILD PROTECTION CONCERNS CONTACT XDHB Other issues • Parents are not routinely informed of the Alert informed of the referral to CYF the option to inform is considered “it is reasonable to assume that the clinician considering whether or not to inform parents / guardians of the CPA will generally come to the conclusion that it would not be in the best interests of the child” (Privacy Impact Assessment) • Alerts are removed at age 17 years or earlier on request, with approval of the MDT the health information is not removed Other issues Antenatal alerts • Antenatal alerts can be placed on the mother’s file; they can transfer to the child’s file when the baby is born and their NHI number is generated • MDT review occurs prior to discharge from maternity services (6 weeks) Sibling alerts • Siblings may be alerted as they are included in the notification of the index child NCPAS infrastructure • • • • • • • Memorandum of Agreement (governance) Policy for alert placement and response Terms of reference for MDT Standardised documentation forms IT process that alerts visible in clinical setting Training (included in core VIP training) Standard processes for privacy of information, event reporting and complaint management • Flowchart for clinician response • Evaluation activities National framework Memorandum of Agreement Formal approval process Biennial review Monitoring & evaluation National and local QI Staff training VIP core training package Process supports Access to consultation National resource kit Quarterly meetings CPAS CPAS Policy MDT TOR documentation forms Resources Flowcharts Current status • CPAS included in cross-sector, national policy documents • Health target to have all DHB on system by 1 July 2015 • 16 DHBs approved to load alerts on National Medical Warning System (approx. 84% child pop coverage) More than 10,000 alerts placed Information is being shared between DHB Examples of flags to information in multiple DHBs Biennial review process indicates that the System operates consistently So what next? • Formal national evaluation planned Quantitative Qualitative Inter-rater reliability between MDT • All DHB on CPAS Conclusion A nationally consistent CPAS: is achievable would enhance information sharing between DHBs has national and local level support balances competing ethical principles should enhance practice should improve child safety If you have questions about: The status of NCPAS in your DHB, please contact your DHB VIP or Child Protection Coordinator The NCPAS and its infrastructure please contact: Miranda Ritchie National VIP Manager for DHBs Chair of the Paediatric Society of New Zealand Child Protection Special Interest Group Health Networks Ltd Havelock North [email protected] References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Ministry of Health. (1998). Our children's health: Key findings on the health of New Zealand Children. Wellington: Ministry of Health. Fergusson D et al. (2000). The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults. Psychological Medicine, 30: 529-544. NZHIS and Police statistics. McKibben L, DeVos E, Newberger E. (1989). Victimization of mothers of abused children. Pediatrics 84: 531–5. Edelson J (1999). The overlap between child maltreatment and women’s battering. Violence Against Women; 5: 134-54 Fanslow J and Robinson E. (2004). Violence against women in New Zealand: prevalence and health consequences. NZMJ 117(1206). Morris A. (1996). Women’s Safety Survey 1996. Wellington: Victimisation Survey Committee and AC Nielsen McNair. Young, W. Morris A, Cameron N, Haslett S. (1997). New Zealand National Survey of crime victims 1996. Wellington. Campbell J. (2002). Health consequences of intimate partner violence. The Lancet 359(9314): 1331–6 Fanslow J et al. (1998). Indicators of assault-related injuries among woman presenting to the emergency department. Annals of Emergency Medicine 23(3): 331–63. Felitti V et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. American Journal of Preventative Medicine 14(4): 245–58. McFarlane J et al. (1996a). Abuse during pregnancy: associations with maternal health and infant birth weight. Nurs Res 45(1): 37–42. McFarlane J et al. (1996b). Physical abuse, smoking, and substance use during pregnancy: prevalence, interrelationship, and effects on birth weight. J Obstet Gynecol Neonatal Nurs 25(4): 313–20. McFarlane J et al. (1992). Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 267(23): 3176–8. Office of the Commissioner for Children. (2000). Final Report of the Investigation into the Death of James Whakaruru. Wellington Office of the Commissioner for Children. (2003). Report of the Investigation into the Deaths of Saliel Jalessa Aplin & Olympia Marisa Aplin. McLaren, Z. (2004). Implementing a Child Protection Alert System. Unpublished paper. Privacy Information Act; Privacy Information Code, 1994. Child, Young Persons and their Families Act, 1989 64 Services for Children in Care Budget 2011 provided government funding for services to address the needs of children and young people in care. The package includes: • Gateway Assessments (health assessments and education profiles) • mental health services for children and young people in care • funding for early childhood education for children in care, aged 18 months to three years. Gateway Assessments - Overview Gateway Assessments are an interagency project between Child, Youth and Family, Health and Education. Their aim is to: > identify health and education needs early > ensure interagency agreement on how best to address needs > facilitate access to appropriate services > ensure children and young people get the support they need at home and at school. 67 68 A Case Study Hi I’m Hemi • I’m of mixed descent and • I’m 9 years old. 70 My Story • Unplanned baby • Born 28 weeks • Home from NICU at 41 weeks on oxygen. • Chronic lung disease • Respiratory distress syndrome • Cyst on brain • Mum already struggling with 3 older siblings Home at 41 weeks of age • At Home: Mum, siblings aged13, 10 and 8 • Jealous siblings: hated the attention I needed • They pulled out my breathing tube • Child Youth and Family(CYF) and Police already knew my mum and brothers. My Home at 6 years of age • 18 year old sibling: In Jail for assault • 15 year old sibling: Living between addresses. Has hit me • 13 year old sibling: Had left school at 11 years. Youth Justice and Police involved. Has yelled at me. • Siblings are using alcohol and drugs • Siblings have hit and verbally abused mum. • The police knew our house My Mum could not protect me Mum could not protect me How did I cope? • Locked myself in the bathroom for hours. (mum told me to) • Mum and I would leave the house at night when my siblings were angry • I was too scared to sleep by myself. • Turned up TV volume or playstation to stop hearing the fighting. My school at 6 • • • • • Liked control: charming/manipulative Hated not being ‘first’ Hypervigilent, confrontational Outbursts of rage, scared other kids Yelled, spat, bit, kicked, swore, destroyed property • Learning stopped • Didn’t know how to keep friends Disassociated my feelings CYF and me • CYF has known my family since 1994 • 31 Reports of Concern about us – mainly from the Police • Mum often rang CYF for help • My social worker worried about me • Support Order so I could still stay at home Kate really cared about me Kate really cared about me How did I Feel? • • • • I really loved my mum I was scared of my siblings My family was not like other families Mum always gave me food and clothes • I was sad, angry, tired, scared I just never felt safe I just never felt SAFE “My mum was a love me, love me not mum”. T 78 1st Gateway: 2011 • Brought everyone together • Started going to health appointments that I had missed • Went to Special Services Unit • Had a therapeutic needs assessment • Me and mum did Parent Child Interaction Therapy together • School was better: started learning and knowing how to cope Things were finally getting better for me and then ...... • In 2012 my mum became partially paralysed through illness. • I thought she was going to die • I couldn’t live with my mum • I had to live with other people • My siblings weren’t safe enough to look after me • I tried to be brave and good • I had scary panic attacks 2nd Gateway: 2014 • • • • I was back living with mum Kate suggested another Gateway visit Kari Centre – not mental health Updated Therapeutic assessment – Specialist Services Unit • 1/1 Art Therapy • Updated Specialist health checks • Identified supports for mum But ..... The arguments between my mum and sibling started again. My social worker was worried and decided it wasn’t safe for me at home anymore. Temporary custody agreement first and then Section 101: Custody order My Life Now: Happy that all the people in my life are working together because look at what I am up to now: Lollipop boy, Hip Hop, swimming, drums In a new school-working at the right level, Creative, laughing, having lots of exciting new experiences, holidaying Sharing in special family moments - with both my families 83 Gateway Summary • Brought all professionals together • Identified his extensive needs including emotional and health • All health, social and educational information about Hemi is in one clinic letter • Provided access to Paediatrician, SSU therapy, mental health services. • Clarifies pathway for his future 85 Gateway Assessment National Child Protection Alert System Violence Intervention Programme Children in Care Programmes, FVIARS Maternity Care Wellbeing Child & Child centred Protection Children’s Teams, MDTs for severe behaviour Shaken Baby Prevention Programme Reduce family violence: partner abuse and child abuse & neglect It’s Not OK, White Ribbon, Local Alcohol Plans, Well Child/ Tamariki Ora, Family Start, PAFT, HIPPY
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