Program Details

Practice Type:	Promising
Program Name:	Comprehensive Sexual Assault Examination Response
Organization:	Brevard County Health Department
Web site:
Overview:	Sexual Violence (SV) is a significant problem in the United States. In the United States, one in six women and one in 33 men reported experiencing an attempted or completed rape at some time in their lives. Sexual Violence can lead to long term health problems to include; chronic pain, STD, unwanted pregnancy, headaches, and stomach pain. Sexual Violence can have significant emotional impact as well, usually manifested as fear and anxiety. Feelings of anger and stress can create and lead to issues of trust, wariness of involvement with others, eating disorders, intrusive memories of the assault and major depression to the point of suicidal ideation. Victims of SV need to be appropriately managed by both the legal and the medical community since this is an issue of criminal activity as well as health. 1. Provide a 24/7 comprehensive, individualized, victim centered care in an outpatient secure environment. 2. Improve the current process of care delivery by reducing victim and law enforcement wait time per exam. 3. Provide quality and continuity of care in a cost-effective manner. Goal Summary: Provide compassionate, comprehensive, individualized care to victims of sexual assault in a comforting environment. Outcomes of practice: In the two and one-half years of operations, this program has managed for over 180 victims of sexual assault. Over 50% of the total volume of sexual assault in the county is now seen outside of emergency departments (ED). The net effect is a reduction in time for the victim and law enforcement, an increase in emergent care capacity, a decrease in overall cost, and an increase in continuity of care for the victim with linkages to ongoing community services.
Year Submitted:	2010
Responsiveness and Innovation:	Sexual Violence (SV) has a tremendous impact on the local community. Sexual Violence can lead to long term health problems and emotional distress if not appropriately managed. In addition, SV impacts the emergency medical system (EMS), social services support system, and legal system to include county and local law enforcement agencies. Historically, in Brevard County and throughout the state and nation, emergency departments have been the location for conducting sexual assault exams. They have the medical staff and are operational 24/7, thus providing access when needed. With the exception of physically traumatic sexual assault requiring emergent care, most exams can be managed in a non-trauma clinical setting. Doing so reduces a tremendous burden on the EMS in both capacity and cost.With the events of Sept. 11, local systems became more fluent and aware of various resources and processes within the community. This is especially true with regard to the emergency medical system, law enforcement and the local county health department due to disaster preparedness planning and exercising. There was currently a system in place to deal with the public health issue of sexual assault but as agencies began to become more familiar with one another, current practice was reviewed and questions were raised as to resource allocation and process improvement. The Sexual Assault Victims Services (SAVS) took the initiative to address the long waits in emergency departments as well as the added expense to ED’s and law enforcement not to mention the victim’s experience. The SAVS office then contacted the Brevard County Health Department to see if there would be a better way to address this public health issue as well as the Salvation Army to get input from the victim services side. The overarching relevancy to the community is capacity, time management, and cost effectiveness.This innovative collaborative effort addresses the issue of SV by improving upon the delivery of services to victims and maximizing existing community resources. Through a coordinated effort, examination of victims is now accomplished at the most appropriate venue with the least amount of time and expenditure. Emergency departments now have additional capacity to practice emergency medicine, law enforcement has more time to devote to investigative work, and victims receive care within the network that will follow them post traumatic event. The victim is seen in a shorter time period for forensic exam, there is reduced time for the investigative interview, follow-up exams are scheduled on the spot at the local health department (LHD), and victim support services are readily available, which includes protective sheltering. 1. The practice is not completely new to the field of public health. Through networking and internet searches there are several private foundations that practice using a similar model (Fort Wayne). In addition, there are LHD’s who have partnered to contract these services within the community or have provided varying degree of support in order for exams to occur outside of the emergency room. In essence, a modified MAPP process was used to develop this practice within our community. Partnership development is an ongoing process and essential in today’s fiscal crisis. From the outset, the vision for this center and practice was the driving force behind bringing everyone together to make it happen; improve care to victims and maximize community resources. Assessments were made within each stakeholder agency to ensure that their strengths were brought to the practice along with their ability to leverage change within the community. Strategic planning was accomplished along with formulating goals and strategies to achieve a unified vision. Planning, implementation and evaluation completed the process. In following the MAPP outline, this practice was able to be up and running ahead of schedule and required very few adjustments during startup. Of the approaches that exist, this is the only one where the LHD has the lead medical role and has partnered with the major investors to accomplish a fundamental change in the delivery of services. There are programs where an individual LHD employee is contracted to provide forensic exams either in a private office or and emergency room setting. In addition, there are programs where the LHD provides some administrative contract management as well as some personnel for exams. This program is unique in that it forms a strong bond between those most affected: the victim, the emergency department, local law enforcement, local social services, the LHD, and the State Attorneys office (including the Sexual Assault Victims Services division).We began with an endpoint in mind. The following questions were at the forefront of our strategic meetings and helped to clarify the vision. Would a change in practice benefit anyone and if so, who? Was this a valuable service that would be of tangible benefit to both the community as well as to the agencies involved? Was it possible to achieve the desired results given the challenges and constraints? Once these questions were answered as YES, it became easy to implement the MAPP process. The Brevard County Health Department (BCHD) maintains a very visible presence within the community via provision of direct services as well as providing technical assistance and expertise to numerous boards and community action groups. An example would be the relationship between the BCHD and the local hospitals to provide surge capacity during disasters as well as implementing a maternity program whereby all women in the county have access to prenatal care. Specifically with this practice, the BCHD is a conduit for all aspects of medical care and communicates weekly with the SAVS office. In addition, all stakeholders participate in a quarterly working lunch at a local restaurant to discuss sex crimes within the community. This collaborative effort fosters communication and system improvement. The BCHD collects and analyses data from each sexual assault and shares findings with stakeholders at those meetings. Each agency involved has the commitment of the highest leadership as well as operational support. There is an overriding desire to make it work. The relationships are professional, collaborative, and remain focused on the end result – which is client centered with a focus on improving the existing process. Clear goals and objectives made it easy for agencies to come together and by-in to the process without the usual territorial posturing that sometimes occurs. The practice truly is the focus in meeting the client and communities needs and all agencies have come together in a seamless bond which makes it happen.
Agency and Community Roles:	The Local Health Department’s (LHD’s) role in this practice is to provide the medical personnel, prophylaxis, some durable supplies, and medical administrative oversight to the exam center. All forensic examiners are either full or part-time employees of the LHD. All timesheets for on-call and examinations are prepared and paid through the LHD, although the funding comes from the Sexual Assault Victims Services (SAVS) funds. The SAVS office is billed on a monthly basis for on-call salary. The Bureau of Victim Compensation is billed on a case by case basis using their Sexual Battery Claim Form (same form used by emergency departments). Exam and prophylaxis protocols are developed and maintained by the LHD. In addition all medical supplies including medication for sexually transmitted disease and emergency contraception are provided by the LHD. All cases are coordinated and filed through the LHD Community Health Director’s office. Although this was a new hands on practice for the LHD, the desire to be active in direct services has been a mainstay of this LHD given the obvious rewards of actively taking care of the community. The community as a whole was extremely involved in this process. The SAVS reached out to both the emergency departments of six area hospitals, the county sheriff department, 10 municipal police departments, the LHD, as well as engaging their existing partnerships such as the Salvation Army’s Domestic Violence Shelter. Each stakeholder had a vested interest in making every effort to ensure the practice succeeded. The SAVS office, LHD and State Attorneys Office had the lead in planning and implementing this practice. Other stakeholders were kept appraised of progress and demonstrated their overwhelming support as each law enforcement agency, most emergency departments, and countless community service organizations were represented at the facility open house. In addition, various agencies had gathered donations such as clothing for the victims, digital camera, computers, exam tables, and a plethora of start up equipment needed to open the doors.
Costs and Expenditures:	The project was implemented May 1, 2006 through a partnership between the Office of the State Attorney (SAO) 18th Judicial Circuit, Sexual Assault Victim Services (SAVS), Salvation Army’s Domestic Violence Shelter, and the Brevard County Health Department (BCHD). The SAVS Foundation obtained a $20,000 grant to support on-call payment. The SAO pays the medical providers for the forensic exam through a victim’s advocacy fund. The Health Department contributed $6,000 of in-kind administrative cost, non-reimbursed medical support, and medical supply cost including prophylaxis medication. The Salvation Army contributed a renovated facility that houses the exam room in a very secure location and obtained local donations for other medical supplies and office supplies. 1. The Sexual Assault Victim Services Foundation wrote and obtained grants for the on-call pay needed for the medical providers. The State Attorney’s Office pays medical providers for exams through the victim’s advocacy fund. 2. The Salvation Army wrote and obtained grants for renovations to facilities and relied on the local community for donations for comfort items such as clothing and food. 3. The Brevard County Health Department provided the staffing for medical examiners through reimbursement via the SAO victim’s advocacy fund and initially used general revenue money for start up costs and continued purchasing of medical supplies.
Implementation:	Sexual Violence (SV) has a tremendous impact on the local community. Sexual Violence can lead to long term health problems and emotional distress if not appropriately managed. In addition, SV impacts the emergency medical system (EMS), social services support system, and legal system to include county and local law enforcement agencies. Historically, in Brevard County and throughout the state and nation, emergency departments have been the location for conducting sexual assault exams. They have the medical staff and are operational 24/7, thus providing access when needed. With the exception of physically traumatic sexual assault requiring emergent care, most exams can be managed in a non-trauma clinical setting. Doing so reduces a tremendous burden on the EMS in both capacity and cost.With the events of Sept. 11, local systems became more fluent and aware of various resources and processes within the community. This is especially true with regard to the emergency medical system, law enforcement and the local county health department due to disaster preparedness planning and exercising. There was currently a system in place to deal with the public health issue of sexual assault but as agencies began to become more familiar with one another, current practice was reviewed and questions were raised as to resource allocation and process improvement. The Sexual Assault Victims Services (SAVS) took the initiative to address the long waits in emergency departments as well as the added expense to ED’s and law enforcement not to mention the victim’s experience. The SAVS office then contacted the Brevard County Health Department to see if there would be a better way to address this public health issue as well as the Salvation Army to get input from the victim services side. The overarching relevancy to the community is capacity, time management, and cost effectiveness.This innovative collaborative effort addresses the issue of SV by improving upon the delivery of services to victims and maximizing existing community resources. Through a coordinated effort, examination of victims is now accomplished at the most appropriate venue with the least amount of time and expenditure. Emergency departments now have additional capacity to practice emergency medicine, law enforcement has more time to devote to investigative work, and victims receive care within the network that will follow them post traumatic event. The victim is seen in a shorter time period for forensic exam, there is reduced time for the investigative interview, follow-up exams are scheduled on the spot at the local health department (LHD), and victim support services are readily available, which includes protective sheltering. 1. The practice is not completely new to the field of public health. Through networking and internet searches there are several private foundations that practice using a similar model (Fort Wayne). In addition, there are LHD’s who have partnered to contract these services within the community or have provided varying degree of support in order for exams to occur outside of the emergency room. In essence, a modified MAPP process was used to develop this practice within our community. Partnership development is an ongoing process and essential in today’s fiscal crisis. From the outset, the vision for this center and practice was the driving force behind bringing everyone together to make it happen; improve care to victims and maximize community resources. Assessments were made within each stakeholder agency to ensure that their strengths were brought to the practice along with their ability to leverage change within the community. Strategic planning was accomplished along with formulating goals and strategies to achieve a unified vision. Planning, implementation and evaluation completed the process. In following the MAPP outline, this practice was able to be up and running ahead of schedule and required very few adjustments during startup. Of the approaches that exist, this is the only one where the LHD has the lead medical role and has partnered with the major investors to accomplish a fundamental change in the delivery of services. There are programs where an individual LHD employee is contracted to provide forensic exams either in a private office or and emergency room setting. In addition, there are programs where the LHD provides some administrative contract management as well as some personnel for exams. This program is unique in that it forms a strong bond between those most affected: the victim, the emergency department, local law enforcement, local social services, the LHD, and the State Attorneys office (including the Sexual Assault Victims Services division).We began with an endpoint in mind. The following questions were at the forefront of our strategic meetings and helped to clarify the vision. Would a change in practice benefit anyone and if so, who? Was this a valuable service that would be of tangible benefit to both the community as well as to the agencies involved? Was it possible to achieve the desired results given the challenges and constraints? Once these questions were answered as YES, it became easy to implement the MAPP process. The Brevard County Health Department (BCHD) maintains a very visible presence within the community via provision of direct services as well as providing technical assistance and expertise to numerous boards and community action groups. An example would be the relationship between the BCHD and the local hospitals to provide surge capacity during disasters as well as implementing a maternity program whereby all women in the county have access to prenatal care. Specifically with this practice, the BCHD is a conduit for all aspects of medical care and communicates weekly with the SAVS office. In addition, all stakeholders participate in a quarterly working lunch at a local restaurant to discuss sex crimes within the community. This collaborative effort fosters communication and system improvement. The BCHD collects and analyses data from each sexual assault and shares findings with stakeholders at those meetings. Each agency involved has the commitment of the highest leadership as well as operational support. There is an overriding desire to make it work. The relationships are professional, collaborative, and remain focused on the end result – which is client centered with a focus on improving the existing process. Clear goals and objectives made it easy for agencies to come together and by-in to the process without the usual territorial posturing that sometimes occurs. The practice truly is the focus in meeting the client and communities needs and all agencies have come together in a seamless bond which makes it happen.
Sustainability:	There is no question regarding the intent to continue this practice and 100% of stakeholders are committed to the practice. There is overwhelming evidence to support the cost savings, time savings, agency efficiency, community benefit and positive feelings of job satisfaction resulting from the care of victims and partaking in the process to get criminals off the street. Each agency involved has the commitment of the highest leadership as well as operational support. Feedback from the hospitals, law enforcement, social service agencies and the victim themselves has all been full of accolades and recognition of community and individual value. Funding remains the primary burden for sustainment. The biggest challenge will be to replace the grant for the on-call funding, which goes through 2010. The LHD is strongly committed to this project as it has remained virtually budget neutral. As the fiscal crisis continues, there may actually be too many staff who volunteers for the practice, but staffing has remained stable for two years. Communication between all stakeholders has been paramount in projecting the value of this service. The plans to sustain this practice stems primarily from the ability to maintain as well as acquire adequate funding. The majority of current resources are generated out of the Florida legislature who funds the SAVS program and provides $500 for each forensic exam, regardless of what entity provides the exam. This funding adequately covers the LHD salaries, supplies, pharmaceuticals, and most of the administrative costs keeping the LHD virtually budget neutral. The LHD has been extremely creative with regard to fulfilling its role and responsibility regarding this practice. The grant allocated to cover the on-call payment is in place until 2010 but it is unknown whether this opportunity will remain long term. Efforts are being made by the SAVS office to leverage another funding source to cover these expenses rather than rely on grants.
Lessons Learned:

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