Consider a highway interchange viewed from above. Asphalt roads dive, loop and intersect in a tangle of ramps and junctions. Violence, abuse and exploitation act in much the same way, encircling, crossing and reinforcing many other social ills, from homelessness to chemical dependence. Individuals may enter a cycle of violence or abuse at different points, but all paths lead to the same inevitable end: poor physical health and reduced life expectancy.
Our deepening understanding of physical costs of violence and abuse has profound implications for life and health insurance. RGA’s ROSEBUD® Consulting Group recently invited Pamela DeWitt-Meza to present a webinar on “Intersections of Abuse” to help case managers identify signs of abuse and intervene effectively. DeWitt-Meza is a certified adult, adolescent and pediatric sexual assault nurse examiner and is the founder and lead consultant at Create Impact. Highlights of the presentation are shared below.
The mission of Create Impact is to equip health care professionals to deliver meaningful care at what you call the “intersection of health and violence.” What do you mean?
It’s important for all insurers to understand that there are important intersections, or interrelationships, among poverty, homelessness, violence, abuse, exploitation and other behaviors that create risk. These are really intimately connected and cyclical. And ultimately this cycle results in degraded health that can lead to disease. Some individuals have vulnerabilities that place them at greater risk, but anyone can be can be vulnerable to violence and exploitation because of a situational hardship.
How does this issue affect insurers?
Violence is a health care issue and therefore an insurance issue. It affects the health of our clients, our families and our communities. Just consider the numbers: Globally about 35% of women have experienced physical or sexual violence, and nearly 32% of the women in the United States will be affected by violence within their lifetimes, and a study of studies by the Institute for Women Policy Research found that domestic violence cost the U.S. economy $9.3 billion annually in lost productivity, wages, criminal justice costs and other expenses. Even years after the abuse, victims can incur real and lasting health costs.
We’re also talking about elder abuse and childhood abuse of both sexes. A recent longitudinal study on adverse childhood experiences found a strong correlation between childhood familial abuse and neglect and incidence of serious and chronic disease in later adulthood, including heart disease, obesity, diabetes and COPD.
You mention that certain groups are more vulnerable?
Predators, abusers, and traffickers look for vulnerabilities, including poverty, social marginalization, lack of stable housing, drug use or chemical dependency and a previous history of child sexual abuse.
Ultimately, there are many potential victims of violence.
So what are the signs of violence and exploitation?
I’d ask case managers to just think of a time when you were talking to a patient and something just didn't seem right. You might see multiple emergency department visits in the chart history for things like injuries, broken bones or sexually transmitted infections. Interestingly, multiple ED visits with vague symptoms, such as fatigue, dizziness and chronic pain, have also been correlated with trafficking and abuse. A history of a traumatic brain injury or hearing loss could result from violence. Interestingly, memory problems can result from trauma as well.
Dental issues, skin issues or notes indicating an overall state of neglect can sometimes show up in a chart and indicate an unsafe living situation. Perhaps there is a history of being a runaway. Multiple psychiatric emergencies might be an indication. Multiple abortions or multiple pregnancies, could indicate trafficking or reproductive coercion, and some research has shown that smoking during pregnancy is correlated with domestic violence. Chemical use or drug or alcohol use during pregnancy could be an indication.
Interestingly, the lack of a cell phone can point to added vulnerability from an unstable or unsafe living situation. Conversely, a teen having multiple cell phones could signal a trafficking situation. In a telephone interview, there could be references to somebody else having economic control; maybe an individual confides that he or she doesn’t have access to a checkbook, a driver’s license or passport. Another common situation is an interview subject confiding a history of familial or past violence.
The bottom line is that when people are in situations of poverty or vulnerability, often times they experience a lack of hope. And that could lead to engaging in risky behaviors and vulnerability to all forms of violence and abuse.
A lot of this is ambiguous or very broad. How can a case manager or claims analyst tell from a phone interview what is occurring or distinguish between trafficking, domestic violence or something else?
Most often it isn't the chicken or the egg. It’s the chicken AND the egg. You can see signs of violence and potential mental health concerns, as well as physical health concerns and chemical dependence in the same case. What is important is to be able to connect, communicate empathy and extend hope to the individual so that they may take the first steps toward accessing resources and moving toward recovery.
How does that happen, especially from a distance?
Let me first say that it’s hard work. Again, I think one of the most important things that we can do is offer hope. If we have the mentality that this is a never-ending cycle, and failure is inevitable, and we telegraph that to the client, we will get that result. People can change, and as case managers we need to celebrate and affirm any sign of progress. As a sexual assault nurse examiner, I would tell my patients, “I'm so glad you came in today. I really love that you're taking care of yourself.”
When case managers are interviewing clients and gaining a history, our clients are also interviewing us. People who have seen violence really have antennas up and are distrustful. We must be honest about what we can offer, remain calm, be patient and remain nonjudgmental. Ensure to the best of your ability that you are able to speak privately to your client. Explain mandatory reporting to anyone under 18 and project compassionate concern. Focus on meeting the client’s immediate needs, based on what the client has voluntarily shared with you. Finally, help the client identify who in their circle can help them – for example, a neighbor they can run to in a time of crisis. This is part of an overall safety plan, and this approach helps build on someone’s strengths, which is an important part of taking back control that has been lost in an abusive or exploitative relationship.
People’s situations usually don't change overnight, but that doesn't mean the case manager has not had a positive impact. This is about micro changes that, over time, can build up to break a dynamic of violence. The payoff is worth the work, and I’m talking about much more than reducing risk or controlling costs with better insurance outcomes. We can be instrumental in breaking a gripping cycle of violence, and ultimately, lives can be changed!