NATIONAL Office of Juvenile Justice CHILDREN’S Delinquency Prevention ALLIANCE Hospital Summit Conducted by Midwest Regional Children’s Advocacy Center August 3-4, 2009 1 Acknowledgements: We would like to take the time to thank all of you who participated in this Summit, as without your input, this endeavor could not have been accomplished. Thanks also to all who completed our hospital based CAC survey in anticipation of this Summit. Your responses were immeasurable in serving as the basis for the Summit discussions. Special thanks to: Kim Martinez, MRCAC Outreach Coordinator, for much time spent analyzing all Summit recorded data, and her excellent compilation of all Summit efforts to create this paper. Additional thanks to: Northeast Regional Children’s Advocacy Center (NRCAC) Southern Regional Children’s Advocacy Center (SRCAC) Western Regional Children’s Advocacy Center (WRCAC) *The Regional Children's Advocacy Centers are funded by the Office of Juvenile Justice Delinquency and Prevention (OJJDP)* Staff: Jane Braun Project Director MRCAC Kim Martinez, Outreach Coordinator MRCAC Anne Cherek, Training Coordinator, MRCAC Lynn Rioth, WRCAC, Colorado Springs, CO Maria Gallagher, NRCAC, Newtown, PA Anne Lynn, NRCAC, Newtown, PA Karen Hangartner, SRCAC, Huntsville, AL Guest Faculty: Karen Seaver Hill, NACHRI Rebecca Gordon, Missouri Kids First Laurie Blumberg-Romero, CHC of MN Honorary Guest: Louann Holland, OJJDP Participants: CARES Northwest, Portland, OR Kevin Dowling, Director [email protected] Leila Keltner, MD Megan Johnson, Deputy DA CARES Twin Falls, ID Kerry Koontz, LSW Program Coordinator [email protected] Patricia Billings, PNP Det. Becky White, Twin Falls County Sheriff’s Dept. 2 The Chadwick Center, Rady Children's Hospital, San Diego, CA Charles Wilson, Director [email protected] Cindy Kuelbs, MD Rady Children’s Hospital John Philips, Chief Deputy County Counsel Niagara Falls Memorial Medical Center, Niagara Falls, NY Ann Marie Tucker, Director [email protected] Jack Coyne, MD Robert Zucco, ADA CAC at Pinnacle Health Systems, Harrisburg, PA Teresa Smith, Director [email protected] Ellen Dyer, CRN, Medical Director Gina Pupo, M.ED., BSN Aetna Foundation CAC at St. Francis Hospital, Hartford, CT Regina S. Dyton, MSW, Program Manager [email protected] Audrey Courtney, APRN Eduardo Rivera, MSW, Dept. of Children and Families Program Supervisor Cooper-Anthony Mercy CAC, Arkansas Janice McCutcheon, Director [email protected] Marcie Hermann, SANE-A/P Aaron Triplett, AK State Police- Crimes against children division Child Abuse Program-Children's Hospital of the Kings Daughters, Virginia Jane Hollingsworth, Psy.D.Executive Director [email protected] Dawn Scaff, R.N. Pediatric Forensic Nurse Examiner Joanne Glass, LCSW Child's Voice, Sioux Falls, SD Monica Maurer, Director [email protected] Nancy Free, MD Lt. Bruce Bailey, Sioux Falls Police Department Blank Children's CPC- Des Moines, IA Chaney Yeast, Manager [email protected] Rizwan Shah, Medical Director Alena Honeick, Family Advocate CAC at Nationwide Children's Hospital (CCFA), Columbus, OH Shari Uncapher, CCFA Program Manager [email protected] Ranee Leder, MD Sonya Harrison, Supervisor, Franklin County Children Services MCRC- Children's Hospitals and Clinics of MN, St. Paul, MN Maureen O’Connell, Program Manager [email protected] Carolyn Levitt, MD Tina Curry, Supervisor, Ramsey County Child Protection Women & Children's Hospital- Charleston, WV Maureen Runyon, MSW LCSW [email protected] Lt. Greg Young, Kanawha County Sheriff's Dept 3 Hospital Summit August 3-4, 2009 Executive Summary The hospital based child advocacy center has a unique place in the child advocacy center. While the majority of child advocacy centers are freestanding 501c3 or under umbrella organizations, there is a subset of child advocacy centers that are either government based or hospital based. The National Children’s Alliance (NCA) has 702 CACs currently (465 accredited and 237 associate/developing). Out of this total of 702, only 48 centers are considered hospital based CACs. In late spring of 2009, a computerized survey via Survey Monkey was sent out to all 48 hospital- based CAC Directors (as identified by each regional Project Director). CAC Directors were requested to forward the survey on to their multidisciplinary team members and medical provider(s). Once the survey results were collated, a list of CAC responses was gathered. Thirteen teams comprised of the CAC director and representation from both the medical and multidisciplinary teams were invited to attend. This invitation was as a direct result of responses by these centers on a national survey about hospital based CACs. Only centers that responded to the survey were considered as potential invitees. Each regional then chose two-three teams to invite and a formal invitation was extended to these teams On August 3-4, 2009, a Hospital Based Child Advocacy Center Summit was held in Bloomington, MN to look at the unique issues that hospital based child advocacy centers (CACs) face on a day- to-day basis and what makes them different from other CAC structures. The Summit was structured around looking at the feedback from all associate and accredited member hospital-based CACs nationally regarding the NCA Standards for Accreditation, a holistic MDT point of view, and other core issues related to the unique setting of hospital based CACs. The outcome of this Summit generated the strengths of hospital based CACs, challenges faced by these unique centers, as well as ideas for strengthening/improving the hospital based CAC in the future. 4 METHODOLOGY: The Survey was conducted in the Spring 2009 with the intent to look at the strengths and challenges of hospital based CACs. Procedure: The survey was distributed to the CAC directors of the 48 hospital based centers (as identified by the regional project directors) to distribute to their multidisciplinary team members and medical director as well as to complete by the director themselves. Design: The four regional child advocacy centers decided to look at the unique issues of a hospital based CAC and subsequently developed a survey to be sent out to the 48 programs. Each of the Regionals brainstormed, edited and drafted the questions to be included in the completed survey. The survey was developed on Survey Monkey so that they could be completed electronically and the results were tabulated directly from the electronic survey. The survey itself consisted of 25 questions, looking at basic demographic information as well as asking about the strengths and challenges of hospital based CACs based on the NCA standards of accreditation. Respondents: Seventy-five out of 144 possible surveys were returned via Survey Monkey (52% response rate) with 40 of these being completed in their entirety (53%). Respondents included medical providers, CAC directors and members from the multidisciplinary team for each hospital- based CAC. Survey Response by MDT position 19 20 e 15 t a r 11 e 10 ns 10 o p s e 5 R 0 Director Medical MDT MDT title Limitations: Because this survey was done on a voluntary basis, not all hospital -based centers completed the survey. Only those centers that responded to the survey in its entirety were included in the subsequent results. 5 Definitions: What is a Hospital Based Child Advocacy Center? A hospital based CAC is a child advocacy center located within the hospital campus, either directly within the hospital structure or housed elsewhere in a separate building/location within the hospital campus. Hospital based CACs are unique in that they have direct access to the services provided by the hospital as well as operate under the confines of the NCA Standards. While most child advocacy centers have their own separate board of directors, their own funding streams and operate under their own structure, hospital based CACs are but one department of a larger structure within the organization. Hospital based CACs must comply with both hospital regulations as well as follow the NCA standards. RESULTS: Respondents were asked about their length of time in their current position. The average length of time was 8.3 years with a range of 1 year to 27 years. In addition, they were asked about the population service area. The range of service populations by respondents was 10,000-3,000,000 with 7 respondents indicating that they were unsure of the population service area size. Respondents were also asked about the average number of children seen per year. The average number was 820 with a range of 60-1772; 4 respondents were unsure of the number serviced. Respondents indicated that they serve an average of 14.3 counties with a range of counties anywhere from 1-53 counties served. Eight respondents indicated that they do not have specific counties that they work with; they have limited Memorandums of Understanding or did not know how many counties the CAC serviced. CAC Setting (percentage of centers within each setting; combination includes a mix of urban, suburban and rural) Successes and Challenges Identified from the Survey: Respondents were asked about their perceived successes and challenges for the hospital based CAC using the NCA Accreditation Standards. The responses reflect all completed surveys with the most common responses listed. 6 1. Multidisciplinary Team Successes Challenges Well-established Lack of funds and resources Co-location Personality/MDT conflicts Commitment from team Poor attendance to appointments and meetings Expertise Poor communication Reduces number of times child is seen MDT turnover Good collaboration Board of directors-lack of, poor participation and understanding Funding from the Hospital Lack of space Referral Ease 2. Cultural Competency Successes Challenges Diverse staff and families Updating competency protocol Access to on-site interpreters Hiring diverse staff Staff workshops/trainings Lack of diverse community-how to incorporate that into a CAC Positive relationships with outside community Lack of bi-lingual interviewers resources Intra-agency experience Inflexibility/inability towards diversity Providing crisis services Interpreter bias 3. Forensic Interviewers Successes Challenges Well trained/experienced interviewers Need for more than one interviewer in rural setting Most children are referred to CAC for interview Lack of funding due to insurance issues Provided training Managing increased work load without increased FTE Can be used in court Interagency cooperation Prevents multiple interviews Lack of specialization-no continuing ed or peer review Child understands that their body is healthy when MDT cooperation done in the medical setting High standards in a hospital setting Problems with technology Interviews free of charge Lack of debriefing protocol Maintaining neutrality 7 Avoiding duplicative interviews Distance for families to travel Not videotaping interview 4. Victim Support/Advocacy Successes Challenges On-site staff for services Budget cuts limiting VA services Solid relationships with on/off-site MH/Crisis Increased caseload with limited resources and staff resources Dedicated providers Multiple advocates-loss of control for quality Minimal access to care issues Limited service area Bilingual advocate MDT valuing VA role Distance for families to receive services Creating VA job within the hospital system At the hub of a basic program is a physician who has an interest and takes initiative in child maltreatment (NACHRI) 5. Medical Evaluations Successes Challenges Available for most children Appropriate after hour/emergency coverage Well trained examiners Insurance coverage for exam On-site Limited trained/interested staff Treating/identifying non-abuse related health issues Families refusing exam; not understanding why one is needed Peer review system Only examine acute cases or higher risk kids Ability to look at other types of abuse Pressure to see high numbers of children medically Create a system where other services can be added MDT buy-in Parent understanding of what exam can “prove” Reaching rural areas 8 6. Mental Health Successes Challenges Good relationships with off-site resources Families following through/compliance for MH services Specially trained mental health staff Insurance access Standard treatment methods used Lack of appropriately trained trauma-focused/child abuse specific MH resources Wide range of services Limited on-site access Acute/Trauma MH clinic on site Lack of follow-up system Wait lists Rural availability 7. Case Review Successes Challenges Regular meetings (weekly/monthly) Difficult to get all discipline representation Well attended MDT members feel singled out/defensive Can clear up misunderstandings Scheduling Information sharing to other MDT members NCA standards conflict with community needs Utilize sub-specialists within hospital if needed Not always helpful to CPS workers (radiology, genetics, etc) Utilize videoconferencing to reach more team Personality conflicts members Case review is the challenge Loss of neutrality and objectivity Information sharing Not all cases are reviewed Jurisdiction issues 8. Case Tracking Successes Challenges Use NCA Trak Difficult to follow post-CAC visit Local resources to help set up tracking systems Time consuming Ongoing discussion about improvements and needs Obtaining information from partner agencies Identifying a system that meets CAC needs Current system does not fit NCA requirements Not always utilized Cost 9 Data is never complete HIPPA issues NCAtrak is not user friendly or intuitive 9. Organizational Capacity Successes Challenges Supportive umbrella agency-hospital Lack of funding Under large health system; great partnership with Hospital administration turnover=inconsistent CAC local MDTS support Human service agency umbrella has oversight Communication problems Strong support from local children’s hospitals Working within the constraints of various hospital rules that may not be applicable No need for external funding Competition for resources amid other hospital departments Provides in-kind services Poor understanding from hospital about what a CAC does Predetermined and set policies and protocols from External funding not always possible when tied to a hospital for some things larger organization 10. Child Focused Setting Successes Challenges Child friendly Space Improved security system Not keeping up with demand Great art Need more options for teens and older kids Variety of activities Aging facility Kid sized furniture Sound proofing Non-clinical atmosphere Limited in capabilities due to hospital regulations Kids want to come back because the setting is fun Parking 10