Manager with the International Association of Forensic Nurses. Today's webinar is titled Evening Out the Playing Field Health Iniquities in the Medical Forensic Exam. It was made possible with grant funds awarded by the Office of Victims of Crime for the SANE Program TTA Project. I do have a few housekeeping items to cover before we get started. I will start with a brief disclaimer. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. That said, we do encourage you to please use the Q&A feature that you can find down below to ask any of your questions that come up for you throughout the presentation. Tammy will be encouraging you to use the chat that's also available for you to use to engage but also to ask any questions you might have. Since we are in the Zoom webinar format, participants are automatically muted. However, we don't want that to discourage you from engaging. So if you do have something to say, feel free to use the raise the hand feature if you have something you'd like to share. We do also have Amy Valentine with us today from IAFN. So if you do have any technical assistance questions, please feel free to reach out to her in the chat and she can help troubleshoot as well. Lastly, IAFN is an accredited provider of continuing nursing education and so there will be CE available for this presentation upon completing the evaluation. The planners, presenters, and content reviewers of this course disclose no conflicts of interest and the evaluation will be sent via email by the end of the week. With that all said, I would like to introduce you to our presenter, which is Tammy Scarlett, forensic nursing specialist with the IAFN. Hi, everyone. My name is Tammy Scarlett. Thank you, Sarah. Thank you, Amy. Very much. I appreciate it. A little bit of information about me, I'm a forensic nursing specialist at IAFN. I have been for about two years now, but I also practice at a hospital-based forensic nursing program and a local child advocacy center as well. My background is in emergency nursing, so it's kind of a little helpful in understanding some different presentations and different settings. And then I also have my master's in public health, which hopefully lended some insight into doing this presentation. Please, like Sarah mentioned, write any comments in the chat. If I don't see them, Sarah will hopefully keep me up to date on any of them. But I also, like she mentioned, I'm hoping this will be very interactive. This is a great opportunity for us to actually learn a lot from each other. We all have different experiences. And like I'll mention throughout the presentation, we all actually have a lot of really good bridges we've already crossed, right? So you might have an experience that will lend insight to mine and vice versa. So I want to know if there's anything we can learn from each other. Just please put it in the chat and you'll see, I will definitely prompt you when that presents. So to start, our learning outcomes are that by the end of the presentation, you'll be able to verbalize health inequities as it relates to our patient population. And more specifically, we're talking today about sexual assault patients. And then also hopefully be able to formulate a plan to combat inequities within your own practice. So all throughout this, just kind of be thinking about those two things and what you want to learn from this presentation. That being said, take a few seconds and think about your own experiences of trying to access care, just in general. So it could be from any time, any place, any type of provider. So think about trying to find the right provider, discussing your concerns with that provider, especially if they were sensitive concerns and hard to discuss. So I know I find it's not always easy and you might not have felt heard sometimes or maybe didn't get the response you were expecting or the resources you were hoping when you went into that meeting. So think about where those barriers you face because maybe your economic status or the environment you were raised in, or did you actually have advantages due to those things? So just keep those in mind in regard to your own experience. Now think about it also in regard to your own practice as a forensic nurse. Turning the tables, we consider how we as providers are providing that experience for our patients. Are we being receptive? Are we being welcoming? Are we fully understanding what their concern is and what they need? And then we take it even deeper. Think about how we start addressing inequities within healthcare, in the healthcare that we provide. Are we noticing barriers for certain patient populations? Are we noticing biases in our own responses? Or either conscious or unconscious could be either of them. Now consider this as we walk through this presentation. What things are you already implementing in your practice? What are you doing well? What things would you like to implement and how would you go about doing that for individual patient experiences and for your patients in general? To start our conversation day, we want to make sure we understand what health inequities are. This is something that we all might know or we've heard about, but it's a good place to start. Now, when we're thinking about our own experiences and the roles that we play as forensic nurses and how inequities occur in healthcare, we need to be able to pinpoint the problem so that we can accurately address it. All right. So health inequities arise from social determinants of health, such as social, economic, and environmental disparities that can lead to major differences within health outcomes between different societies and even within specific societies. We know that violence and sexual assault do not know boundaries to any specific population, person, or place, and we know that not all things are equal. So let's talk about those inequalities. These are systemic differences where we typically see the lower socioeconomic position at a higher risk of poor health outcomes. So this is where our expertise will be helpful in addressing health outcomes for our patients. And again, like I said, sadly, not all things are equal, despite what we want it to be. And there are two different types of inequalities that I really want to point out. There are health disparities and health inequities. Both are similar yet very different. So health disparities are differences in health status and mortality rates across population groups, which can sometimes be expected, such as the differences in cancer rates in the elderly versus children. Then we have health inequities, which are differences in health status and mortality rates across population groups that are systemic, avoidable, unfair, and unjust, such as breast cancer mortality in Black women versus white women. So for our patients specifically, we can sometimes see inequity in rates of violence, in access to care, and even the response to that violence. So when we talk about equality, we want to recognize it as each person or group of people being given the same opportunities and resources, while equity sees that each person has a different need and therefore resources and opportunity are given to meet that person or group of people and given equal opportunities and outcomes across the board. Now health inequities are preventable, and there are things that can be done to reduce health inequities, which we'll, of course, talk about throughout this entire presentation and we'll discuss together. So think about those throughout the entire process. Digging deeper into these definitions offers insight into what this means within access and quality of care. Again, going back to our original question of what do you see within your own experiences and what do you see as providers, we want to consider that when someone is unable to access care, we then see an overall inability to access those health services to achieve best possible health outcomes. We know that there are many time limits for many aspects of a medical forensic exam. So if we have a patient, say, in a rural area who's unable to get services within 72 hours that they need for the HIV NPEP, then they've missed that window of opportunity. This could be a possible poor health outcome for this patient. We also look at the quality of care as the degree to which health services for our individual patients and our communities can increase the likelihood of those desired health outcomes that we want to see achieved from our exams. So for example, we have a patient who does have access to a hospital within that 72 hours, but that hospital does not have an established SANE program or a SANE on-call, and so that patient is then not able to receive that HIV NPEP because the knowledge wasn't there. So regardless if they presented within that timeframe, then we don't really have a good quality of care for that individual or anyone else who would want access to the medical forensic exam. So we want to make sure that when a patient presents to us that they can receive effective, safe, patient-centered, trauma-informed, timely, equitable care. Now overall, inequities are created when barriers prevent individuals and communities from accessing health care that allows patients to reach their full health potential. Some of these are simple barriers, and some of them are deeply rooted and difficult to change. For me, I think one of the biggest hurdles is being able to categorize some of these barriers as inequities, not just problems that some people face, but defining this within the context of something that can be changed and acknowledging it as that inequity and looking at it through the lens of health equity. Now what we want for better patient outcomes is that health equity. Health equity is achieved when every person has the opportunity to attain his or her full health potential, and no one is disadvantaged from achieving that type of potential because of social position or other socially determined circumstances, according to the CDC. They also state that this equity should be achieved regardless of someone's skin color or historical background, regardless of their education level or health literacy level, their gender identity or sexual orientation, if they hold a job or if they don't, depending on where they reside or where they come from, if they have a presence or lack of any disabilities, or really anything else that would distinguish another person from another. So this would then, you know, determine the care they receive, whether that puts them at an advantage or disadvantage. Now we discussed how health inequities arise from social determinants of health. Well, some factors that play into social determinants of health are the circumstances in which people are born, also the way they grow up, how they live, how they work, and what that affects their health, their functioning, and quality of life. Now we need to be aware of these as it provides, you know, when we provide care in order to understand our patients, understand discharge instructions and resources, especially within our targeted communities. Now if we have a community where education is not as much of a priority, then we might need to tailor our discharge instructions for that health literacy. This is our contribution to leveling out that playing field. But in the long run, we as providers can also advocate for a better response at the community level and we want to consider how we can accomplish this within our response as SANEs and SAFEs. So again, keep that in mind. And then digging even deeper, there are many factors that can contribute to inequities. One big concept being racism. Here we have an image depicting the social ecological model showing racism constructs, all the way from the systemic level down to the interpersonal level. Now on the right, we see what types of things contribute to racism on each of these levels. So think of, you know, your own circles, your own communities. What do you see contributing to this, especially for your patients who experience sexual assault or even other types of violence? And of course, we narrow these inequities even more to health status. And we can see this in the image, how the differences in various groups play out. This data compiled by the Kaiser Family Foundation from 2018 shows the comparison of health status measures from some groups compared to their white counterparts and how some fare, what is categorized as worse. Now these are things that we need to keep in mind, especially about the communities we serve. We don't know the types of communities you serve or actually the communities you should be serving. So who aren't you seeing and why aren't you seeing them? Does this play a role in that? Now how do we consider these determinants of health inequity for our patients? Well according to the American Medical Association, a report from the Institute of Medicine found that there are worse health outcomes associated with disparities in healthcare, of course. And they occur within a context of broader inequality. There are problems on the system level, as we discussed earlier, such as racism. And this can be hospital administration or higher level institutions, on a macro level, all the way down to providers, staff, and even patients that contribute on a micro level. So we know that bias, stereotyping, prejudice, and clinical uncertainty can contribute to all of these. When it comes to our patients, we want to acknowledge that this can lead to possible racial and ethnic minorities refusing treatment, which can be detrimental for our patients and doesn't show us all in a great light. And why would anyone else come seek care from us? Just knowing what these health inequities are is not the only problem. And it's definitely not where we just stop our education. So we must understand how we as healthcare providers can be the problem as well. Michael Foucault, a philosopher, stated, power is everywhere. And that biopower, which describes how institutions can exert their power over the human body in the name of human good, is one of those ways we can exert power. Now one example in the article given is in healthcare, we continue to use lighter skin photos, which leads to disadvantages for those patients who do not have different colors of skin who are not as equally represented. Now this then manifests as a lack of knowledge for identifying injuries when patients who have different skin colors present for care, which of course is a disadvantage for them. Now we've seen this very clearly throughout history, but there are many ways we don't see it so blatantly because it's also been forced through social norms and practices. We as providers of healthcare need to work on going beyond the basics, and we need to work on changing these problems within the institutions we work in. So through the whole system, policies, and actually refusing to participate or engage in these inequalities in our own practice. When nurses or providers are educated and empowered to act at multiple levels, so that upstream, midstream, and downstream, they actually help reduce the effects of structural inequities generated by the healthcare system. So the Harvard Way is a great organization. They discussed some factors of inequality in healthcare, which is adapted here. We see access to care, high costs of care, health outcomes, social factors, and COVID-19 discussed as contributors to inequities and inequalities in healthcare. So think about all these categories in regard to our patients. Where do you see any of these playing out? These seem so simple and so easy to address in some ways, and some seem just inevitable, such as COVID-19. But overall, we can acknowledge and work towards addressing these. Access to care is something I see playing out all across the United States and the world. We see language barriers and how staff react to those, and that can lead to misunderstanding and frustrations. I know we've all probably been there, leading to patients probably not receiving the care that they need. I think about how we can impact care when we attack this head on and use just simple appropriate services for our patients. Now, everyone knows this because it's probably in everybody's training at their hospitals and clinics, but it's actually something that we are addressing across health systems as it's a requirement for care to provide language access. So think about that kind of a response. But we also move down the line, and we see more difficulties in how we would respond. So take out-of-pocket costs, for example. It's not easy to solve for our patients in the moment sometimes, and we have patient compensation and other funds, but what if they don't qualify? And what about that patient who calls asking if they can pay out-of-pocket before they even present to the hospital? How do you respond to those? So these are all difficult to address sometimes, and the difficult part is that promises can't always be made and solutions can't be guaranteed. And then we move to health outcomes and social factors that are very difficult for us in our settings to address, especially in our small briefing counters as providers. And even how do we address something like pandemic? How does that affect our patients? Now, I don't know about you, but sometimes it's hard to even get through my shift with how much there is to do, and there's not always the capacity to address things outside my just simple workday, let alone tackle health outcomes and social factors. But we look at what we can control on the basic level, and that is something we already do for our patients. And we provide a sexual assault medical forensic exam. I always want to back it up and bring it back to the beginning of healthcare and really why we got into this. So we're going to start digging into some foundational principles of the sexual assault medical forensic exam, and we'll tie it all in together. The sexual assault medical forensic exam is based in our foundational nursing practice. It embodies why we do this. Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of the human response, and advocacy in the care of individuals, families, communities, and populations. Now this provides the foundation of why we provide care, and we recognize this statement that it's not dependent upon certain factors that we provide care, yet care is provided to everyone. This also applies to all other fields of medicine, so medical providers, ED techs, CT techs, everyone else has their own definition of practice. So that being said, I can't go into all of those fields, but we all know why we're involved, and we all know the basic concept of our practice. Now we take that a step further to address that nursing is a science. It's a scientific discipline based on principles of the biological, physical, behavioral, and social sciences. It applies the best available evidence and research data to the process of diagnosis and treatment, and it at its core is an art of caring and respect for human dignity. So as a forensic nurse, we have the privilege of caring for patients during some of the most difficult times of their lives, and that quality goes above and beyond not just treating those that present at our door, but sometimes understanding that through the help of science, we can help those who are not presenting, and those who might have those difficulties and those barriers in accessing care, and it's within that art of nursing that we provide that quality nursing above and beyond just our basic checklists, above and beyond just what we have to document in our charting and what's expected of us from that 7 to 7 shift. Now one way to view health equity is through the lens of an ethical clinical practice. This goes along with our scientific and article approach to make sure what we do is again above reproach. So IFS vision as represented here states that the International Association of Forensic Nurses expects its members to aspire to the highest standard of ethical nursing practice. One sentence specifically states providing forensic nursing care in a manner that respects the uniqueness of the patient or client. Now we build a plan of care around patients, and we do not expect each patient to respond the same, to look the same, or to have the same needs, But we recognize our ethical responsibility of bringing this type of care to all patients who need it regardless. A good way of looking at this is to walk through some provisions of the nursing code of ethics. I know this is going way back to nursing school, but it's always a really good guiding document. So other providers, of course, have their own code of ethics to follow. And of course, we're not going to go through that, but same principles apply. So walk into the principles we see that we agreed to treat our patients with compassion and respect, again, for every person. Our commitments are to that patient in the way they need it in a way to provide optimal care for those patients. For example, provision five speaks to an overall comprehensive approach to self and others for maintaining a responsible and competent practice. For example, keeping up on education and ways to address inequities. Maintaining that ethical environment for our patients creates an outcome of safe and quality health care. Along with creating that ethical environment, we ensure an academic environment that upholds professional standards for nursing and health policy. We then come together as professionals to maintain human rights, health diplomacy, and reduction health disparities for our patients. And finally, maintaining professional integrity to incorporate principles of social justice for our patients is also important. Now, of course, there are a few other aspects of the nursing code of ethics, but these directly speak to the care we agreed to provide when we became nurses. And this speaks to the type of care that we should be exemplifying and that our partners, such as law enforcement, advocacy, and anyone else should honestly be expecting from us at all times. These ethical considerations should remind us every time we encounter a patient of what we need to do, not just, again, for some patients, but for every single encounter. We also want to take into consideration our scope and standards of practice for both nursing and forensic nursing. The scope of ethical nursing practice is far-reaching and includes nurses' obligations to patients or clients, the public, the science of nursing, and nursing colleagues. So I'll go through just a little bit of this. Fidelity to patients is important. As forensic nurses, we serve patients and clients faithfully and incorruptibly. We respect patients' confidentiality and inform the patient of the limits of confidentiality based on that practice setting. And then we have responsibilities to the public. So we have a professional responsibility to serve public welfare. We should actively be concerned with health and welfare of the global community. And we should recognize our role in preventing violence that includes understanding those societal factors that we talked about and talking about that oppression that promotes violence. And we acknowledge the value and dignity of all human beings. And we want to really work towards a world where violence is just not accepted. And an obligation to science is where forensic nurses seek to advance forensic nursing and nursing science and understand the limits of our knowledge. And we respect the truth. We should ensure that our research and scientific contributions are thorough and accurate and unbiased and that we're not misusing research, but that we're using it in an ethical way as well. And of course, a dedication to colleagues. So we perform work honestly and competently. We want to make sure also that when we're educating new forensic nurses that we're reiterating these concepts of ethics. We want to make sure we're modeling a role of good ethical nursing. And we're discussing with those new nurses what inequities do and what role they play in our communities and in our practice. We need to keep each other accountable and honest and just honestly hold each other at a level of high ethical responsibility. Something to think about is that maybe some affluent areas may have a way to advocate for their own justice. Justice within the community, they might have a great platform to speak on, but less affluent areas might not have as much mobility to advocate for themselves. So kind of think of that in the context of the things I'm about to talk about. Now, not only do we have legal and ethical considerations, but we also want to consider legal and ethical considerations, but we also want to consider our key principles of beneficence, non-maleficence, autonomy, and justice. Beneficence is doing good by our patients. Non-maleficence is specifically not doing harm to our patients. And autonomy allows self-governance by our patients. And justice can have many different meanings within different situations. But for our patients, it's meaning upholding what is right and just. I can just hear my ethics teacher just being so excited talking about this because it really was one of those classes where I was like, this is a lot to handle. And, you know, I can talk about different specific situations, but now I see how it is literally laced all throughout my practice. It's something that we need to be considering on a daily basis. So these all come together to provide an open and trusting environment along with us always putting our best foot forward for each patient every time. These seem like simple concepts, but I've seen how these can get lost in the process. When other factors come into consideration, we forget what we're really there for. You know, we get tired. We get short-tempered. We're human, right? But we're not judge and jury, and we are medical professionals first, and the health and well-being of our patient comes first. Other stakeholders have different roles to play, but know that, of course, we should all be striving for being a better approach in our care and work. There are also some other considerations such as informed consent, which is to assure that our patient is comprehending and understanding that entire process. And that is informed consent is providing that throughout the entire exam and not just at the beginning. This is through written and verbal consent. As a side note, the difference between assent and consent, you know, we can go into a whole presentation about that, but we'll kind of talk about that a little later. There are things that I personally take for granted sometimes in my own world since I understand informed consent a little better, of course, since being on this end as a nurse, but that doesn't make it any less important or real for someone who has to live through this. So putting ourselves in those shoes and understanding what informed consent really is and how we get that across that patient and how we help them through that process. Now, also establishing trust is really important. It's a good idea to be upfront and honest with our patients, which, of course, we all inherently know, but veracity, which is the complete truthfulness with patients and not withholding the truth when it may lead to patient's distress is imperative. I know we probably have all run into that, that situation where we might have to report after we told them we might have to report, and we have to kind of backtrack a little bit when we find out new information. That's really hard, but being upfront and honest, regardless if it leads to distress, is really important. So if we make this a safe place where we have justice, autonomy, beneficence, all these things, it leads to patient outcomes that are positive. And then looking specifically at health inequities, how do we look at these and what can we do? So we're going to advocate for our patients first, and I know this sounds simple again, but it goes back to those basics of what's doing what's right. So standing up for our patients. In the same vein, we need to acknowledge the little things, not just the big things. If they are only demonstrating patients of a certain color or gender, then we need to rethink that, right? If we're seeing that only on the pictures or the pamphlets that we have, we need to be really rethinking that. Or if our policy does not have the language to be inclusive of different ethnic or minority groups or different genders, then we need to be able to change that as well. And then, of course, looking at our own bias. Now, we might not think we have this, but it's surprising what we do not realize about ourselves. The implicit bias training through our social justice committee was eye-opening, and it's actually really important, and I think it's something everyone should actually try and take. So it goes beyond just the basic decisions we make, and we need to acknowledge that. These are just some things to consider. There's even more specifics we can do when it comes to seeing and treating our sexual assault patients. Okay, so now think about what we discussed in these concepts. Of course, they're vital to our foundation for practice. So let's see opportunities to implement them in the sexual assault medical forensic exam in order to combat those inequities. I don't know if everyone's able to, but what are some patient populations that we see that might not be receiving equitable care? So everyone kind of think about it for a couple seconds and maybe put some populations in the chat, things that we all should be thinking about if anyone has any specifics. I'll give everyone a minute. For me, I think about maybe Native and Indigenous communities. I think about care and rope people of color, absolutely. Families who are English as a second language, LGBTQI and human trafficking patients, absolutely. Those with a criminal past, maybe. Those who have encounters with law enforcement. Those with behavioral or mental health concerns. Yeah, so start thinking about those groups as we go through this. We'll kind of play that in a little bit. Then, who do you think these people receive care from? We have us, but when they come in contact with the medical system, who else are they seeing? So think through your process at your facility. I think in my response for healthcare and the hospital-based system, they see intake and triage. They might see a medical provider or other nurses who are helping me in my process, and then first responders as well. So think about that. Maisie wrote foster care, those in foster care. That's a great idea, too. That's really thinking outside that box. Okay, now all through the exam, not only us as healthcare providers, but all those people I mentioned. So anyone encountering these patients have an opportunity to approach the patient with extra care and consideration. So think back to patients you've seen throughout these next few slides, and what could we have done differently, or what else could we have added? Or actually even think about the great ways you've actually already implemented this care. We're all doing really good work, and we don't even realize it sometimes. A lot of us are doing this without even thinking about it, and we need to acknowledge our wins and growths. However, could there be more room for improvement? So let's dig into the medical-friendly exam a little bit and think about it. Karen also wrote registration, security, affiliated care providers, uneducated and non-trauma-informed providers. Exactly. So we'll get to a case study towards the end, and that's exactly something I want to think about, is how do we educate those people? So keep that in mind. All right. I, again, am a big supporter of going back to where we came from. So it's good back to go over exactly what the exam is. Now, we all know what it is, but again, it's a good idea to get back to the basics. So according to the U.S. Department of Justice's Office on Violence Against Women, the medical forensic exam ensures that patients have access to medical, legal, and advocacy services, again, despite what background or circumstances may present. Now, this should be provided in a coordinated, multidisciplinary approach. The medical forensic exam will provide those who have experienced a sexual assault with immediate and comprehensive care they are entitled to, and the trauma-informed approach will help decrease any trauma they may be experiencing, with also the use of community resources such as safe housing, advocacy, legal assistance, and more. Through this process, we can encourage public safety through investigation and prosecution, leading to offender accountability, and possibly prevent future violence, which works towards equity. Now, education on the resources and exam can raise awareness in the community and within our own health care, you know, response, and it can lead to trust, and possibly for the victim to seek out this help and disclose the violence. Now, remember the purpose of the exam will help us move in the right direction, and again, get us back to why we started this, and move us towards an equitable response. Considerations in the medical forensic exam are important. So, we start to approach every situation the same, in regard to every patient, so every person is equally deserving of that respect and attention. In that manner, we look at it, that we're approaching it the same. Yet, everybody needs their own understanding and response to meet the where they're at. So, that means doing easily understandable introduction. Now, discussions of reporting options and consent, and gaining that history from that patient is really important. So, going in without preconceived notions or judgments with the beneficence and non-malfeasance like we talked about is imperative. Now, we also offer that autonomy we addressed when we provide fully informed consent, and then of course, like I mentioned before, think about how hard it is to Like I mentioned before, think about how hard it is to get to that exam, all that it took to get that person there to see us. We need to be able to address any concerns someone might have in order to make this a trauma-informed and patient-centered exam. That means making sure that all opportunities are presented equitably, not just equally, and then the physical and anogenital assessments are perfect opportunities to allow for autonomy and non-malfeasance as well. So, we approach this part with an open mind of what that patient needs, not my idea of what should be done or what should be expected, and if I think that evidence collection is the end-all, be-all, that I'm doing a disservice to my patient if that's not what they need. So, for some patients, their culture or beliefs dictate a different approach, and this is that perfect time where I can either choose to exert our power over our patients, or where we can offer them that power back over their own health care. If a patient doesn't want that anogenital exam or if they don't want evidence collection, are we able to ask why and maybe find out ways to work around that, or just address that main concern and ditch that part of the exam if that's what's best for them? Photo documentation and evidence collection fall within these categories as well. So, we think about offering photo documentation. For me, it just seems so normal, but for others, it might seem exploitive or something that we might need to consider working around or talking with them again about why this is concerning. Now, also think about evidence collection and those who might consider a way to get their evidence used against them. Not everyone has a positive history with law enforcement, and everyone is not trusting of the system. So, thinking about these things and being able to discuss this openly with them might be a good opportunity for someone to make a decision that's best for them. Discharge and follow-up is a perfect time to break those barriers and those gaps as well. We can present education on an appropriate learning level for health literacy and choose to sit down and provide the resources necessary for success. When we take time to offer appropriate follow-up resources and discharge, we can encourage equitable access to care and encourage trust. I want to dig into discharge and follow-up section a little bit more. Now, this is an opportunity for all of us to step up and not just hand out discharge instructions, which I know all of you are not doing, but we can actually make some changes. The National Academies of Sciences, Engineering, and Medicine all describe this pretty well. They said that in many clinical settings, individuals may be hesitant to provide information about issues such as housing, food insecurity, and more. However, we are actually in a perfect position to address some of these concerns when we're obtaining our psych social information because we're prepping for discharge with that as well. So, consider what seems to me to be important, might not be important to someone else, like we talked about. And if someone needs food or housing for stability and to feel safe, then that's important. And we need to maybe rearrange our process and rearrange our understanding of how that exam should go. This is a very important opportunity that we can address realistic expectations and realistic problems for this person. When we meet these patients where they're at, they might then be able to focus on other things such as evidence collection or pelvic exam, things that are important for them in the long run, or they might be important for them in the long run, but things that they didn't necessarily see as an immediate concern compared to food and safety. Not only that, but consider we have a good view of what is happening in our communities when we gather this type of psych social information. This allows us to step into that role of addressing inequities within our community and hopefully targeting issues prior to patient's arrival within the same setting. So, consider addressing these within your SART or within advocacy programs or within government legislation on a local or national level. Now, within Discharge, we have an amazing opportunity to help someone have a leg up after the exam. We're able to help set up a follow-up appointment, get them to the right resources such as advocacy, and get them community resources for their social needs. This is where we are able to provide more targeted resources for these patients. Again, I go back to our original slide where we thought about the difficulties in our own way of accessing care. Now, consider you just had a long, very, very long exam sometimes. You have to get home for your next shift and you have your children to take care of. Life picks up again. Now, imagine having to set up follow appointments and get medications on top of that. Well, what are the ways we can actually reduce those barriers? Can we set up follow appointments? Can we work towards that as a program or team to make sure that's something we can establish for every patient if they need it? Is there a way to make sure we can get patients medications prior to them leaving or at least get them to a pharmacy that carries those medications so they don't have to travel to multiple pharmacies? Or can our pharmacy carry those meds? So, we think about ways to set our patients up for success after they leave and we want to, again, meet them where they're at in this regard. And a final aspect of the exam is considering billing. Now, is victim's compensation or an other equivalent resource accessed in your program or your area? And what if patients don't want to report? Will their medical forensic exam cost be covered regardless or only part of them? Do you even know? Does someone in your program know? Do they know what their rights are? Now, are they seeing a SANE or are they seeing only a registered nurse or provider who's been pulled to do that exam from their main patient load? And do they know the answer to those questions? Do you or some of the programs in your jurisdiction eat some of those costs or, for example, maybe the evidence collection kit is paid for but not the medications or other costs? Will that be easily done in an area where the hospital is not as easily able to take on the cost? So, for example, can your hospital even take on that cost? The Urban Institute talks through some options that are good to consider, such as making sure there is access to victim advocates during the exam process that will be able to help with those considerations, making trained examiners available and those who are especially able to answer those questions and know where to send patients for resources and follow up with those questions. And then know the answers about billing or get them to the correct person for billing. I know our registration is really helpful with that, but we've had to educate them and actually ask them some of those questions too, and that's been really beneficial for our patients. And then, of course, a systemic solution of increasing the confidence in the criminal justice system response equally in all areas so that patients have access to all available resources of funding as indicated. Now, there are also good reminders to make yourself aware of the barriers in your own area. If we do not know all the problems our patients are facing, for example, if we're not aware of how the billing or funding works, then we can't really bring awareness change or fully informed consent to our patients. Now, no patient should be turned away or deterred from accessing care, which includes the medical forensic exam, but this shouldn't be based on their ability to pay. So we wanna make sure we know how we are addressing these things prior to them arriving. Payment TA is a wonderful resource that we have available at IFN. So just a thought, I know sometimes billing can be tough and hard, but we're able to help with questions and resources as much as possible. All right, after talking about a more focused approach during the medical forensic exam, we need to address that every discipline may play a role. Other stakeholders in the response may have a sway over the access and care these patients receive. For example, consider if a patient has had a previously bad experience with law enforcement or the criminal justice system, this might make them hesitant to come in for fear they might be arrested or blamed. Now these patients might also not want to come in for fear that nothing will be done because this is their experience, but they've had in the past with maybe local advocacy agencies or local hospitals in the past. However, these stakeholders might also be a driving force for good in the community and addressing these inequities. I think specifically about local law enforcement agencies who strive to actually work very closely with SANEs to address any of these concerns, such as officers who might not be approaching patients in the best way. So this is an order to make sure that those patients receive the best and the same care across the board for that equality and equity, that they're not denied care or belief just because of their past history, where they come from or where they look like. I also consider maybe hospitals that got all their staff trained on no sane insights so that they know how to give all patients that care they need, regardless of what occurred or how the patient presented. So keep in mind who you want to target in your community as a leader to help with the response or someone you might need to come alongside of and provide that extra support and education for the response. So while we move on to the next slide, go ahead and write in the chat. Can you think of anyone in your community, staff, stakeholders, anyone else that might be a part of that response that might need extra education or might be pulled in to help with that response because they're doing a really good job. So please feel free to write that in the chat. Sometimes it's good to learn from each other. So while we move on, EMS is an excellent one. Law enforcement, great. Okay, the National Sexual Violence Resource Center addresses educating other staff and community members in their document that's called A Health Equity Approach to Preventing Sexual Violence. This is one of their blogs. So we want to not only address things in the acute phase, but we're actually set up in a unique position as forensic nurses and those who address sexual violence. We're in a position to help address these inequities from all different angles, including prevention. Now, these are some considerations they suggest. These are some things we discussed, but we're gonna look at them in a different process and a little bit of a different comprehensive view here. To start, we want to elevate community leadership and resilience. We discussed bringing change on that macro level. Well, this is the perfect opportunity to have a voice of the community and leadership. If leadership at your hospital, clinic, or on your SART does not reflect what your community looks like or doesn't even know what the needs are of the community, how are we saying that they're truly addressing a good approach to sexual violence for these patients? Then we see creating spaces for healing in prevention efforts is where we see trauma-informed care as an imperative part of our approach. Now, providing healing spaces that show some main nursing concept we discussed earlier, such as respect, autonomy, informed consent, simple things that actually go a long way. Not only that, but addressing that there is trauma, that there is a need for healing, and coming about this in an out-of-the-box approach in order to not just address surface needs. But like we discussed, what does that patient need to heal? They need safety, they need food. Sometimes they think different than us and different than when I'm initially seeing that patient present. So sometimes things that we do not see right away are the most imperative need. But through this, we can bring in our community members also and start to address healing on a community level. There's something to be said about being a part of prevention as well as treatment, as they really go hand-in-hand. And then facilitating organizational change is important. They discuss in the document that you need to basically be walking the walk. And we suggest reflecting on questions as an organization, such as, are individuals with disabilities being heard and considered within our organization? Or are our spaces and our approach accessible to everyone? If not, how do we change these? See, we can't begin to change unless we're asking these questions. Even simple changes such as bringing education, such as organizational-wide education on bias and accessibility, those requirements that you have in your yearly trainings, those are actually really important and bring awareness and education to those staff. So this is where leadership can reflect that community. They need to be close to that community and they need to understand that community so that they can lead the rest of the organization in that regard as well. Now, there are many underlying factors that contribute to violence and safety, and we have talked about them throughout the entire presentation. But think about what does this look like in your community? Are you in a small community where everyone knows everyone and therefore violence is something that should be solved within a family network according to social norms? Of course, that would shape how a response is made in that entire community, all the way from family members reporting all the way to how law enforcement responds. Now, this document suggests challenging current norms by uprooting and refusing to reproduce them in a collective effort. That is where community comes in. So can we start in our SART to address changes? Our sexual assault response teams can be very effective. Now, we see how domestic violence laws are changing and how mindsets of arrests are progressing towards a positive outcome in some areas compared to what it used to be. Now, we know that change is possible. We know that there's opportunity for learning and growth, but we have to bring awareness and address it in ourselves first. And then within the pathways we can bring change, that'll start to change. So consider working with public health, community development, schools, and other areas that these changes can directly affect our patients and communities. And then finally, to elaborate on that, we need to collaborate with all types of organizations across all fields. There's a wealth of knowledge and resources out there that can actually help. And someone might have already crossed that bridge that you're approaching, and they might have something that could facilitate that approach. So think about organizations within your community and outside your community. There's a ton of technical assistance resources out there. Not only that, but there's coalitions and so many other organizations that are working to bring positive change. Okay, so here we see a different list of those we can educate as we want to make sure we're all learning from each other and growing and fostering a relationship of respect and trust as we go. Now that list of other stakeholders that you all have mentioned, care and added crime labs, local pediatricians, nursing schools, and colleges, these are great responses. So again, feel free to write down any entities or groups that you've worked with that someone else could possibly learn from or consider. So for example, with law enforcement, like discussed earlier, it might be one of the first groups to respond to patient encounters, and this can make or break an initial impression. So maybe consider going to officer training and educating them about what the medical forensic exam is, what biases are there within the response to sexual violence, common misconceptions about patients who present, and this is not to tell them that our way is the only way or that we're the only ones that can educate them, but this is an order for them to see from our perspective to learn what we know and what we've already learned. Or EMS and paramedics might be the first person to make that contact, and we should have the exact same education going to them as well. So they might be the first person to respond, like I said, and they have a quick focus response, and they could provide pertinent information to law enforcement, advocates, medical staff, in order to make sure they have a heads up about that community the patient came from or something the patient said. So consider, sometimes the first comment by someone who interacted with that patient is written down in that chart. It's then taken as truth. And I think sometimes things written down in charts or those first initial comments are those little tiny microaggressions, those little tiny micro comments are things that can sway someone's opinion going forward, and we don't want that. So we wanna make sure that our first responders are responding in an approach that is founded in truth, that's unbiased and is only beneficial in working towards an equitable response. And then them to us as well. So we wanna make sure that when we get there, we're open to facilitating that discussion. So what have they learned as well that we can learn from? That's a great point, Karen. And then hospital clinics, child advocacy staff, so some of those other people we mentioned earlier, they're key groups to educate. They're also very busy at times too, and they can have a focused approach, but they might encounter many of our patients and they need to have just as much training and education as us, as this is overall a comprehensive approach that we're going for. Other suggestions are maybe local shelter staff, substance use organizations and mental health organizations, as they might encounter our patients before they're referred to us. So they might get them first and then refer them to us, or we might refer them to them or send them to them after their discharge. So something to think about. They can also be perfect for that continued trauma-informed approach when patients go to them instead of seeing us. So making sure that everybody in that response is touching this kind of equity. Again, we also need to make sure we have an accurate representation of local population on our SART teams. So our hospital boards and other decision makers need to reflect this as well. It's definitely hard to create a policy or guideline to be inclusive when we don't even have buy-in or say from those who we're trying to make decisions for. So having supportive backing from the top down on these decisions will create accountability and following through on these policies and procedures that would be inclusive of any person or population. This again, will set a foundation that will support a strong response to sexual assault, not only within the medical forensic exam, but with every person who encounters these patients. Now that top-down concept or even group concepts, again, come into play because we can have the best intent. But like we discussed, if we don't really have everybody involved in that response small break in the chain can really make everything fall apart or make one person just stop and maybe not go forward. So we wanna make sure we're all working together. Overall, we work in a field that needs a lot of work, right? And there will be always a need for change. There will always be challenges and room for growth. However, we know that there are options for change and we know that there are many different pathways either within our sexual assault medical forensic exam or even looking at road a patient might travel to get to us or to get follow-up and resources after us. So consider, what do you want to accomplish? Where do you want to start? Where do you wanna end up? I encourage you to think about some patients you have had and the process that they went through that journey that they might've had. And what can you do to bring equity for the next patient? All right, bringing all this together, bringing everything we talked about together, we're gonna dig into a little bit of a case study. Now, throughout that, I want you to consider the following. Now, this is not an exhaustive list. However, it's a good quick glance at some things that might be predisposed barriers to accessing equitable treatment after a sexual assault. Now, think back to those social determinants of health that we reviewed. So the circumstances in which people are born, the way they grow up, the way they live and work that affect health, functioning, and quality of life risks and outcomes. Things that we can work towards to change. So keep these in mind as we go through these two patient encounters. Okay, so we have two separate patients here. Now, these are modeled after patients I have had. So it's not a true story. I changed some things just so we can learn and kind of to bring some things down so we don't have a huge, huge case study. But we have patient A, which is a 35-year-old female who presented to a hospital in a more resourced community. Patient A presented where a SANE program was available 24-7. The patient was accompanied by a support person and presented within 24 hours of the assault and was requesting to have advocacy present. Now, patient B was a 25-year-old female who presented to a hospital in a less resourced community after a sexual assault. There was no SANE available at the hospital. And so the patient had to be transferred to the nearest hospital with the SANE. The patient also presented with her three-year-old and five-year-old daughters as she reported she had no one to watch them. And she presented about 70 hours after the assault as she could not miss work. She declined advocacy when asked, stating she had worked with them in the past and it just didn't really feel like it was successful. So when we look at that, we think to ourselves, how do we even the playing field? What are the differences? What are we noticing? And how can we go forward with this? Does anybody have any suggestions? You're more than welcome to, we can raise your hand and we can unmute you, or we can just walk through these together if you have anything you wanna put in the chat. But I think about what was the initial information? Does anyone think that this was an equitable access to care? Is this just how the world works? How so? Why not? Now, remember, equitable access would be each person having access to a SANE. So how do we make sure there is care in every hospital or area near us, within every hospital system, or even in our state? Is telehealth an option in this scenario maybe? Now, I think to myself, what are the barriers this patient had in accessing care? Was there maybe access to childcare? Could a support system or a family or friends had come and watch the child? And why not, if they couldn't? Would someone maybe have been there to support her, regardless of the children? Now consider, if the patient had declined advocacy, is that systems-based advocacy, community-based advocacy? Do we know why they declined advocacy? Again, digging into asking, can I help you overcome this? What's going on? Maybe we can get you a different advocacy agency. Maybe you don't want them right now because you just don't want them to come out because it's late, and you wanna follow up with them later. So how do we get that person the care they need in the way they need? Okay. So to continue, patient A stated she already knew her reporting options as she was able to look them up and decided on a full report to law enforcement. Consents were reviewed and signed, all questions answered, no issues. She was good to go with the exam. Patient B was not aware of her reporting options and declined to involve law enforcement as she was afraid she might still have a warrant out for missing a court date. Consents were reviewed and signed. However, patient stated she'll have to leave and return later when she can get a family member to watch the children. So she ended up returning later that night. Someone wrote, thinking back to the last slide, perhaps if a sexual assault could be triaged as an emergency, it is although often not life or death, patients would fall under more legal protection for care and many laws need to be changed and states need to become more uniform in terms of healthcare access. So how does that look? What does that look like for these patients? Exactly. Do we maybe tell everybody they have to have the same? Does that present more problems for patients? So these are things we can think about. What does your community need? What do those laws look like in your community? Okay. So with this case study scenario here, this part of the consents, how do we even the playing field? What are the differences? So just as a first thought, how did you picture these women? Different? Similar? Just curious. No one has to say anything, but I'm just curious what everyone's first impressions of these people were. So something to consider is health literacy level of this patient. So are we providing fully informed consent if this patient didn't really know what was going on, if they didn't know what their reporting options were? Or did they just not know what their reporting options were because they didn't have access to technology? So does that have difficulty in bringing equitable access of care to our patients? If one was able to look up and think about what reporting options they wanted and one couldn't, it kind of had to make it on the spot. Is that a disadvantage? So I think about also how can we get patients information, not information about patients, but information out to patients prior to them coming. So if we think about, if I don't have access technology, how am I made aware that I need to come to get the same exam or that I can come to get the same exam and that there are options? Is this being disseminated in schools? Is this maybe posted up somewhere? Is this being advertised anywhere? So how am I supposed to make decisions about my healthcare when I don't even know what those options are? What about language? Verbiage that's recognized in that community. So that patient had to come back later. Did she know how long the exam would take? Did we accurately present it to her in a way that she would understand? I'm not saying we didn't. I'm just curious, thinking about those things. We think about translators, American Sign Language, things that maybe can help patients get that care equitably. Also consider information we provide the patient about possible warrants being out for her arrest. What do you all think about that? I know I've definitely had this situation and it's really hard. So that person is now at a disadvantage because they're worried about something from their past coming to maybe be a barrier. So do I have a good relationship with local law enforcement to understand their response to this? I know in our community with warrants, they'll usually put them aside in the context of a sexual assault so that they can just address that sexual assault in the moment and they'll follow up with that patient later. So if I know that, can I promise that? Can I not promise that? But can we as providers maybe provide education to law enforcement about, hey, when you come, can you talk to us about how we're gonna address this? Is there someone who can help with watching the children so maybe she doesn't have to leave and return again? That's something to think about. Do we know about free access to childcare in our communities? Is there someone there in the hospital that can help? Just watch those children for a little bit so that we can get her the care she needs. And of course, we understand that some people just really don't wanna report for some reasons that are out of their control, and that's absolutely okay. But how can we help manage care around that? Do we know what is out there for these patients for resources? So we need to consider that. Okay, so someone wrote, A, being a white person, B, being a person of color or lower socioeconomic status and opportunities. And then are the hospital staff people from the community? That's a great question. Does anyone who works there look like this patient? Maybe this patient didn't wanna be there after realizing what happened and signed those consents and left, and maybe would never return because of realizing that upon presentation. Urban or suburban versus rural residents. I don't think it's, I do not think color language or educational health literacy, but I agree these are often factors. Patient B seems to have had institutional betrayal or has personal biases from perhaps real harm from institutions, professionals, didn't like didn't want an advocate and from providers, especially with no SANE available. So does she have money to travel to a site where the SANE is located? That's a great question. And I often see patients not choosing to continue with that part of the care because they don't have a ride. They don't have money to get there. And then how do they get back on top of that? So these are great thoughts, great questions. Okay, next. Patient A, the psych social is patient lives with her husband and they do not have children. She doesn't work at this time and her husband works for a technology company. She denies any intimate partner violence and she denies any alcohol or drug use. Patient B lives with her two children, her parents and three siblings. She reports she works part-time at a local restaurant and receives WIC and food stamps. She reports she's in an on and off relationship with her children's father and does report IPV, but she denies any alcohol or drug use. Just to keep in mind, she went back home, dropped the kids off and then came back and was reconsented and she's good to go for the exam. So are there any considerations for these two patients that anyone's thinking of? I think something for me that stood out was co-occurring violence is something to consider. So does she recognize, patient B, that violence is abnormal? Maybe this patient would have presented sooner, like patient A, if violence maybe wasn't a part of her life. I don't know, maybe, maybe not, right? So are there some confounding factors here such as work, children, co-occurring violence? That could be something we could help her out with, especially education around violence, I think is something that maybe could help, I don't know. But we discussed earlier that things that might be important to a patient in order to address an exam. So for patient A, she doesn't have to return to work, but patient B does. Patient B might be worried about access to food for herself and her children, which maybe we could offer some food in the meantime. And if we had some there to watch the kid, that might be helpful. Then at follow-up, we might be able to get her in touch with resources that could help with daycare or resources such like food and clothing that might decrease some stress. And then of course, not to make assumptions, but also with having open conversations and addressing this with every patient. We're not showing bias, we're making perceptions, but we want to make sure we're not missing issues with either of these patients. So just because A says there are no issues does not mean that there's not another concern at play. And we want to make sure we're addressing both patients with all those questions. Karen asked a great question. Was there a safety plan for patient B and what does the children's partner know? So we'll kind of get to safety plan in a little bit. That's a great question. So socials are very helpful for understanding how we can get resources to patients. A small thing in my program is that we started routinely asking patients how to call our cell phone, which seems so simple. People are out there every day, right, getting around, but being able to address that helped us game plan with patients for how to get to a pharmacy, get to follow-up, get their lab results later on. And this was imperative to making sure each person had access to care they needed. Okay, so any other differences you guys can think of? Sorry, my dog in the background. Okay. Patient A reports vaginal penetration by acquaintance at a friend's birthday party, but she denied any strangulation. Patient B reports vaginal penetration by a stranger while out drinking at a bar with friends, and she denies any strangulation. Any initial thoughts? Any differences between the two that you guys can think of? Now, for me, some of this was kind of hard to write down. It felt very distinctive between the two women. Again, this is hard to reflect on because I had similar patients like this. But for example, my initial impression of the types of assaults was something I had to check myself on. We know it doesn't matter what type of scenario led to assault, but there are preconceived notions out there about drinking at a bar versus drinking at a friend's house. This is something that social norms have set us up for failure in, and to believe that there are differences, right? So checking yourself and acknowledging that this is an issue and how do we address it? So once I address it, once I acknowledge it, then I just need to address it head on, right? So within our staff and within our own response. Now, some of the things, these things are not necessarily things we can petition for change for. Like I can't petition like laws to make people think differently about how we would perceive these two women in the situation. However, I can bring change by changing my own thoughts, my approach, and keeping myself accountable for my actions. I want to change the narrative in my own life so that others will see that around me. And I also want to keep them accountable. So as a team, how do we bring change? And then, you know, as a ripple effect out to law enforcement, who's then coming in next, and then advocacy, anyone else, they'll see that change within us and hopefully change that narrative. But another thing is we see both patients denied strangulation. Is this because we asked both patients, right? We didn't assume one would tell us because maybe one had more violence in the past or one denied any IPV. So we're assuming, you know, there's no strangulation going on anywhere, but we want to know that this is dangerous and we need to address it in every single patient. All right, patient A, physical assessment showed no body surface injuries, no anal genital injuries, and she had negative GCCT and wet prep. She's on birth control and she just recently went to her OBGYN and she wanted evidence collected. Patient B had no body surface injuries, no anal genital injuries and positive chlamydia. She reported she had not seen her primary care provider, OBGYN, since she had her baby, since the baby was born and she's not on birth control. So keep in mind her youngest was three. Karen added, do case reviews at ED staff meeting and discuss implicit biases. That is great. And I'm actually gonna point that out. I think it's a great point. And these are things that if you're noticing these, bring them up, talk about them as a team. We don't want to keep them hidden. We want to bring them to the light. So with that last part, how do we even the playing field? What are the differences? Any considerations we need to make here? Again, don't make any presumptions about positive results. The chlamydia could have been from the assault. It doesn't mean that it was from a previous encounter with anyone or it could be from her partner and she didn't know. So why doesn't she have access to her primary care provider or OBGYN? Is this something she's had for a long time and could have gotten that care if she did have access to that? I also think to myself, maybe there's some reproductive coercion going on here. Is that something that we need to address? Especially with, is there control in that intimate partner violence? Is there difficulty getting somewhere because the kids, because of child care or transportation? Is that something that maybe we can reach out to advocacy or other resources to help her get? Now, I also want to consider why does someone decline evidence collection? Is there a lack of knowledge surrounding what the process is? Could we have educated on that to bridge that gap? Or again, something like we mentioned earlier, something someone could fear could be used against them. These are big conversations we can actually address in our SART. Do we need to start talking about what the education process is and if this could be used against them? Now, I know that's not something happening everywhere but there is talks about that nationally, right? And then do we need to return at a later time or did that patient need to return at a later time to come back to do it? Is that okay? Have we explained that timeframe to them? And if that's what they need, cool. Do we modify that? Or maybe they don't know the timeframes associated with evidence and we need to actually walk them through that. Again, not everybody comes to the table with the same information. And then cultural and religious beliefs might be a barrier and that's something we can actually definitely process through. And that's not enough time for this presentation. There actually is information out there about how to address that and how we can conceptualize around that. Another thing to think about is, like Karen said, does patient B have health insurance? Maybe that's why she's not accessing care. Does patient A not have insurance and maybe she's going somewhere for indigent care? So something to think about and we don't wanna make assumptions or assume. So that's a great question. Okay, patient A is on birth control and declined emergency contraception because of that. She had requested the GCCT and TRIC prophylaxis, but she declined HIV and PEPC and she didn't think she was at high risk for this. And then patient B did request contraception and she said she's not on birth control and she requested the prophylaxis as well, but also requested HIV and PEP. However, she voiced that she had concerns over being able to fill the prescription as she doesn't have insurance or a way to pick it up. So what are the differences and how can we help even the plain field in this scenario? Again, that insurance, that's a great point, Karen. So if someone doesn't have insurance, can they get access to birth control? Do we know where they can get that access? Or maybe do we have a reliable contact or follow-up for an OB-GYN who would be able to help them with this? Someone who actually maybe knows about that trauma-informed practice and is able to maybe get this patient on birth control at the same time that they do all the other follow-up, that might be very, very helpful. Could the medications be provided onsite or at a related clinic? Great question. What about access to HIV and PEP? This is a huge problem in some communities. So where's the nearest place that this is stopped? If she doesn't have a car, it's gonna be very, very, very difficult for her to access it for patient B. Will insurance even cover it? Some insurances don't cover it. And so just because she has insurance, we can't make assumptions. What if someone doesn't fully understand and is having a hard time grasping HIV and PEP? Do we have all the answers for them? Can we be able to articulate it in a way that makes sense to that person? So again, educating ourselves and being prepared to assist our patients through that tough pathway is a good way to even that playing field. We might not have all the answers right away, but when we do our best and we try and meet them on our app, we can hopefully come up with some good outcomes. So work with Victims' Compensation, work with your local pharmacy, work with the pharmaceutical companies. We know there's, again, a lot of resources out there, a lot of people who have already broached these pathways. So know the options in your communities, your local family practices, pediatricians, public health departments, basically anyone these patients might come in contact with. We also need to be reaching out to them so they know to continue that process seamlessly and to continue that collaboration. We want them to have a trauma-informed response. We want them to be knowledgeable as well. So when these patients leave us, they have a good trusting relationship too. Okay, and then discharge. So patient states she feels safe to return home, patient A. Patient reports she can set up a follow-up appointment with her OB-GYN on her phone at this time, so she's already doing it. And she has a card to get to her follow-up appointments. She feels safe to return home. So to answer your question earlier, Karen, both of them have good safety plans and that was solved and were addressed and they're good to go home. Patient B is requesting assistance with transport home though, as her friend who drove her back is unable to pick her up. And she reports she does not have transport or childcare to get her prescriptions tomorrow and is worried she might not be able to get to her follow-up due to a lack of a car. I don't know about you, but I see this all the time and it's actually very frustrating and defeating because I feel like I don't always have good answers. Don't always have those resources to get patients home. We don't always have all the solutions, but do we have an advocacy agency in our communities that can maybe assist? Do we work with local travel agencies such as Uber or Lyft? Maybe they can do discounts. So consider the time we were discharging our patients. Is it safe to take a bus? Is it fair to ask them to take a taxi after what just happened? So we have options, but we also need to consider the best options. So we need to process this with our patients though. So we want to give them that power back. So I'm not just deciding that an Uber or Lyft or riding with advocacy is the best option. I'm making that decision with them. I'm presenting those best options and giving that opportunity. Now, like I said, this is a really hard one. We want to consider follow-up, transportation, childcare. There's so many things, but is there anything that's available in your community? And will certain funds be available to maybe help with childcare? Maybe we can get her a work excuse. And can we write down maybe a work note as well? Let's see. So some people wrote, takeaways we must get out into our community and learn about our resources and possible referrals. Absolutely. And then patient B, you may reintroduce the idea respectfully to any advocate who may have additional resources and can walk through local resources, laws, and potential supportive care. Exactly. Getting down to why that relationship maybe wasn't working so well. Can we figure that out? Maybe readdress it. So great. And then patient A, patient reports she's feeling well and was able to get a follow-up appointment with her BCP and OBGYN when we called three days later. However, patient B, we were unable to get ahold of and her phone was not set up for voicemail, which happens I feel like often. So set up your voicemails, everyone. Okay. This is a really hard one as well. Patients being lost to follow-up is really frustrating and difficult because again, I feel like I failed. So is there something we can do to help set up a system before they leave maybe? Maybe instead we suggest asking if they want to call us back in two days for results, not just assuming that everybody will get a follow-up call. Now, other ways that have worked for you guys, go ahead and write them in the chat. Maybe something you all have learned from and maybe something that works in your community. But again, going back to one of the first slides when I asked about encounters with healthcare, I think about for myself how difficult it is to get in touch with my provider sometimes. Those missed calls back and forth, having to set up appointments, not knowing the number, where to look. It's difficult. So addressing these upfront can actually help, again, meeting our patients where they're at. Did we set up a follow-up appointment prior to them leaving? That would maybe help set up, help decrease the steps that they'd have to follow. Also, maybe she might not be able to answer her phone ever because she's at work, she's with the kids. So if we know an appointment is already set up, she knows that too and she's able to make the appointment but she's not able to answer her phone and that's where we can meet her at. There's some really good answers here in the chat. So something I'm not pointing out yet, which was a little work we did with patient A. So actually it was just a little work, right? There were a few considerations we had to make. We thought outside the box to make sure we address some of the concerns with patient A as we did with patient B. So we made sure we're meeting both of them. But overall, we did not really work hard to get her the resources or care she needed because she was already set up for success and that's fantastic. We want that, right? But we also want that for patient B. We want patient B to be afforded equitable access as well. However, regardless, we will have some patients who present new and different challenges. We'll have some patients who already have predisposed barriers and some that might not seem as obvious to us, right? Some answers to the problem are small, like setting up a fall appointment and some answers are big, like bringing system-wide and community level change. Regardless, we need to address what we can and work on what we know and what we can control in our response. So consider, what health outcomes do you want to see in your communities? What do you want your approach and your response to be to patients? And how will you work to learn and grow and improve with every single patient encounter? Now, this could be something you learn as a team or as a hospital system, and maybe even bring change in form of case studies like Karen mentioned. So bringing those specific encounters and learning something from them every single time. What could we have done differently? How can we do better? Now, even if we cannot bring change in that moment, you've already worked towards it by bringing awareness. Comfort is easy and change can be hard, but consider yourself in those positions and think about the response you want. Going back to the beginning of knowing what we have experienced when we've been patients, did we like that care? How can we guarantee that for our patients? Did you not like that care? So how do we change that for our patients? And going back to the basics of what we know to be true as nurses, what we know the truth is about the care we provide and the reason we got into this in the first place. Again, going back to overall, inequities are created when barriers prevent individuals and communities from accessing healthcare that allows patients to reach their full potential. Everyone should be able to reach their full health potential. I'll leave you with some extra questions to think about, such as which patient populations do you serve? If I changed out of the case scenarios for these patient populations, what would we see different? How would you respond differently? Are you well-equipped to respond to those? Campus, maybe not for me because we don't really get a lot of campus. And again, why am I not getting a lot of campus students? Is it because someone is already treating them in a different area? Or is it because they don't want to come to me because of barriers and inequities? And then what are things can we incorporate to bring change? Good thing is Advocacy Day through IFN is an eye-opening experience to see how we can bring change through policies and through government education and awareness. Then we can do statewide education. It's a great way to bring awareness to local resources and connections. What about Telestain? Some communities might benefit from this as an option when others are not available. It might decrease some of those barriers and those disparities and inequities. And we also discussed SART. This is a great way to work on your community response. And I highly recommend if you do not have one to implement one and then to work on these with them. And then know your resources. So girls, what you do, what your position, what your role is, if you are just someone who does your shift and leaves or if you're a manager or if you're leading a hospital, it doesn't matter. You need to know what your resources are. So look them up, dig into them. And it's really helpful. I think one of the things I learned from my own team is I learned from someone else. So they might not know the resource I know and that's cool because I can't know everything. So knowing where to go, knowing where your resources are and who to reach out to for those. So how do you want your practice? How do you want to give care to these patients? I really, really encourage you to think about this for the rest of the week. I had to reflect on a lot of things in doing this presentation because it really forced me to think about these when I was writing every single slide. And so it's good to just, again, bring awareness, bring things out of the darkness to light because if not, we're never going to change anything. So that being said, if you have any questions, please feel free to contact me. If you have questions about payment TA for billing, if you have questions about any technical assistance that we talked about throughout here, I'm happy to get you in touch with anyone who can help you or be able to help you in any way I can. Just to recap though, Karen added just some other recommendations. Provide the old CDC recommendations for STI prophylaxis instead of giving her a prescription and then make an agreement with patient to call us back in two to three days. See, there's a lot of knowledge out there with the nurses who have done this. They've been there, they know what works, what doesn't work or what options might be out there. So reach out to us. Karen is also a great resource and we're happy to answer any questions you have. But regardless, thank you so much everyone for coming today. And I really, really appreciate your attention and your patience. And thank you so much for all the care you provide to our patients.

health inequities

medical forensic exam

sexual assault survivors

coordinated approach

informed consent

social determinants of health

targeted resources

advocacy

biases

collaboration

systemic barriers

trauma-informed approaches