Inside Oversight

Adam Roy
Hello! This is Adam Roy with the Veterans Affairs Office of Inspector General. Welcome back to another episode of Inside Oversight, a VA OIG official podcast that examines our oversight reporting of the VA. To understand the complexities of the topics we report on, we talk with the report authors and experts to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public.

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Today, I'm going to be talking to Dr. Amber Singh, an associate director with our mental health team within the Office of Healthcare Inspections. We’re going to be talking about a report the OIG published back in September of 2022 on the Veterans Health Administration’s Intimate Partner Violence Assistance Program, specifically the implementation of this program at VA medical facilities and related compliance barriers.

I will note that just recently our Inspector General Michael J. Missal testified before Congress on how the OIG’s work enhances VA’s accountability and continuous improvement efforts for its services, programs, and operations. In the testimony, Mr. Missal references this report and its findings to demonstrate the importance of establishing clear roles and responsibilities.

I’ll ask Dr. Amber Singh about those related findings later. Amber, welcome to the Inside Oversight podcast. So good to have you hear today. How are you doing?

Amber Singh
I’m glad to be here and really appreciate the opportunity to discuss Intimate Partner Violence, or IPV, which is a such an important public health issue.

Adam Roy
I’m glad you’re here, too. And what do you do here in the VA OIG?

Amber Singh
Thanks for asking. As an associate director within the Office of Healthcare Inspections, I lead inspection teams as we evaluate the validity of allegations or concerns that we’ve received. We then make recommendations to medical center, VISN, and national leaders on how to improve patient safety and quality of care. Sometimes we identify a concern that may apply more broadly than to a specific medical center. And this IPV report is an example of that. During an inspection at a medical center, we identified more general concerns with the IPV assistance program. So, we decided to look at this program, nationally, with the goal of making recommendations to strengthen this important program the VA has implemented.

Adam Roy
So safe to say, you and your team stay pretty busy.

And before we get started, I do want to emphasize to our listeners that we will use the acronym I-P-V in lieu of Intimate Partner Violence throughout today’s interview for brevity purposes.

Also, I’ll add that we will be discussing violent behavior so be mindful of who else is listening today.

If you are in danger, or know someone who is, I encourage you to use the following resources available to you. Contact the National Domestic Violence Hotline at 1-800-799-7233, text “start” to 88788, or chat live at thehotline.org. You may also contact the Veterans Crisis Line by calling 988 and selecting 1, texting 838255, or visiting veteranscrisisline.net to receive confidential support now.

Dr. Singh, I’ll start by saying, when this report was suggested as a topic for the Inside Oversight podcast, the phrase “intimate partner violence” was a bit unfamiliar. What is IPV? And is this a relatively new area of focus?

Amber Singh
IPV is abuse or aggression in the context of a romantic relationship. It can include physically or sexually violent behavior by a current or a former intimate partner as well as psychological aggression or coercive acts, and stalking.

The CDC first started collecting data on the incidence and prevalence of IPV back in 1995 and 1996. In 2012, VHA convened a task force to address the lack of a national policy related IPV, which then led to the development of VHA IPV policy.

It’s also notable that IPV can range in severity and frequency. It can happen in both heterosexual and same-sex relationships, and it does not require sexual intimacy or cohabitation in the relationship. IPV affects all demographics across genders, sexual orientation, age, ethnic identity, and socioeconomic factors.

Adam Roy
And what are the consequences of IPV?

Amber Singh
The consequences of IPV can be quite serious and range from physical injury to negative psychological and health problems. For example, individuals who experience IPV are more likely to suffer from anxiety, depression, posttraumatic stress disorder, and self-harm behaviors and may also experience increased rates of heart disease, digestive conditions, and other chronic diseases. It’s also really important to recognize that individuals who experience IPV are also more likely to engage in risky health behaviors, things like smoking, heavy alcohol use, and decreased preventative health care. So, the impact of IPV can be both overt and subtle and can be apparent both during times of violence and long after the violence has ended.

Adam Roy
You mentioned VHA’s IPV policy or Directive 1198, published in January 2019. Now, the policy considered a medical facility “out of compliance” if a designated coordinator or the implementation of the full scope of services” was not in place as of January 2019. How long has VHA had this program operational?

Amber Singh
That’s a great question. While the program policy was established in 2019, the IPV Assistance Program, or IPVAP, was first launched in 2014. At the time, although they did not have designated IPV coordinators, several medical centers identified a need and began developing IPV-related services, and VHA appointed the National IPVAP manager. Two years later, in 2016, VHA began collecting data to assess baseline implementation status. And then in 2018 the Senate Appropriations Committee directed VA to fully fund IPVAP implementation to include expanding screening and intervention.

Adam Roy
Before we talk about the September report and your findings, help the listener understand how the Intimate Partner Violence Assistance Program is managed and organized at VHA?

Amber Singh
Of course, the IPVAP National Program Office is organized under the Office of Care Management and Social Work Services, which is within the VHA Office of Patient Care Services. The National IPVAP manager reports to the national director of social work, who is responsible for the oversight of the “development and implementation of national directives, program initiatives, and VHA guidance related to the delivery of IPV assistance.”

VHA is organized into 18 Veteran Integrated Service Networks. We refer to those as VISNs. Each one oversees at least one medical center and several community-based outpatient clinics. At the VISN level, the IPVAP program consists of an IPVAP champion who, as a collateral duty, provides support to the VISN lead coordinator. That VISN lead coordinator is typically a facility IPVAP coordinator who takes on additional duties to serve as a liaison between other IPVAP coordinators within the VISN and the national IPVAP manager.

VHA requires that each facility have a designated IPVAP coordinator who serves as the medical center’s subject matter expert, point of contact, and consultant for IPV-related issues and are also responsible for education and training, IPV screening, coordination of services, intervention, and program evaluation. That IPVAP coordinator must be a licensed independent provider, which means that they can provide patient care services independently without supervision, and those independent providers can be social workers, psychologists, professional mental health counselors, advanced practice nurses, or physicians.

Adam Roy
And I noticed that in the report it indicates that veterans and active-duty service members are up to three times more likely to perpetrate IPV than the average civilian. Why might that be?

Amber Singh
The prevalence of IPV among veterans and active-duty service members ranges between 14 and 58 percent, and over a third of female veterans are victims of IPV. We know that veterans have a higher prevalence of some diagnoses, including posttraumatic stress disorder, which may be a risk factor and increase the likelihood of experiencing further victimization such as IPV.

Adam Roy
And I imagine that the COVID-19 pandemic only exasperated these factors? Was there an increase in IPV incidents during the pandemic?

Amber Singh
Yes, the COVID-19 pandemic resulted in a marked increase in the incidence of IPV for a number of reasons. Families remained isolated in their households for prolonged periods of time and may have experienced financial and work instability. Also, social distancing may have contributed to victims being unable to access supportive resources.

Adam Roy
That makes a lot of sense. Prior to this September report that we are going to speak about, had the OIG looked at VHA’s Intimate Partner Violence Assistance Program before?

Amber Singh
Yes, we actually did. In August 2021, we published a report related to deficiencies in the management of a patient’s reported IPV at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina.

Here we found that despite both the patient and the spouse having reported of IPV, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure that the spouse felt safe with the patient returning home following that patient’s discharge. Also, an inpatient psychiatry resident failed to complete documentation within 24 hours, as required, and facility staff did not consider consultation with the Office of Chief Counsel regarding the patient’s IPV.

After the patient’s discharge, outpatient mental health staff also failed to consult with the IPVAP point of contact and didn’t provide the patient and spouse IPV resources and intervention, as the OIG would have expected. We also found that the facility director did not ensure development of an IPVAP protocol, as is required, and that VHA guidance about IPV training responsibilities was unclear. In the end, that report included four recommendations related to staff consultation with the IPVAP coordinator, timely clinical documentation, and consultation with the Office of General Counsel to determine reporting requirements.

Adam Roy
So we had a report at a specific medical facility, and now turning to this report, a national report, your team asked program coordinators and champions to complete an online survey about their duties and perceived challenges to their roles in May 2021, kicking off your initial inspection. Then later in August 2021, you requested that those who completed the first survey complete a second supplemental survey. You also completed telephone interviews with 25 coordinators and interviewed seven champions. That’s a lot of data to sift through, I imagine! Were you satisfied with the response rates? And what did that data tell you?

Amber Singh
It really was a lot of data. We received 135 completed surveys from 143 IPVAP coordinators, which was a 94 percent response rate, and we also received information from 10 of 14 VISN champions. We really did find that the majority of survey respondents and interviewees were enthusiastic about their work. They were committed to the role and thoughtfully considered the challenges and barriers to IPVAP implementation.

Based on those survey responses and interviews, we learned a lot about the IPVAP including information about IPVAP coordinator dedicated time and duties; IPVAP role responsibilities, oversight, and governance; and perceived barriers to implementing key aspects of the IPVAP, like screening.

Adam Roy
So to reiterate, those main takeaways were
1. Coordinator dedicated time and duties
2. The program’s role responsibilities, oversight, and governance, and
3. Perceived implementation barriers.

Let’s start with the coordinator role. I understand that VHA allows the coordinator role to be assigned as a collateral duty with consideration of the size and complexity of the medical center, although VHA also recognizes that it is optimal for a medical center to have a dedicated coordinator. What did you learn about coordinators’ dedicated time and duties?

Amber Singh
VHA does require that IPVAP coordinators have adequate protected time to fulfill the role responsibilities. Although 82 percent of IPVAP coordinator survey respondents reported that over half their time was dedicated to the role, we found that the IPVAP coordinator serving the medical center with the most patients and the IPVAP coordinator serving the medical center with the least patients BOTH reported their dedicated time as between zero and 25 percent. So, there does not appear to be a logical relationship between the IPVAP coordinators’ dedicated time and the patient population size.

Additionally, IPVAP coordinators reported having a number of administrative duties including staff consultation, patient education and outreach, standard operating procedure development, and consult and records management. Despite those administrative duties, nearly 90 percent of survey respondents reported not having administrative assistance, and 80 percent indicated that assistance in managing a variety of clerical tasks would be helpful.

Adam Roy
Now turning to the VISN champions and lead coordinators. During your interviews, what did your team discover about their roles in relation to this program?

Amber Singh
We interviewed seven VISN champions who described their role as providing oversight for multiple programs including IPVAP and also homeless services, mental health, and other special populations such as women’s health, and post 9/11 case management. They also described their role as providing support to the VISN lead coordinators who are more involved in the day-to-day operations of IPVAP. In interviews, the VISN champions suggested that clearer expectations of the VISN champion and VISN lead coordinator roles would be helpful.

Additionally, the executive director of the Office of Care Management and Social Work Services told us that the medical center directors are responsible to adhere to the IPVAP directive. However, the national IPVAP program manager noted that the national program office establishes policy but does not have the authority to ensure compliance. Further, while the national program office can provide support for IPVAP implementation, rescinding funding is their “only recourse” if a medical center is not compliant with implementation in accordance with the directive.

Adam Roy
In addition to compliance and oversight authority, your review looked at program evaluation, too. Specifically, those performance metrics that help VHA leaders, healthcare professionals, and even veterans know if the program is working as designed. What were your team’s main findings?

Amber Singh
The IPVAP coordinator is responsible for program evaluation. However, we found that VHA did not establish standardized program evaluation methods or standardized measures. The national IPVAP program manager told us that performance metrics have not been prescribed and are monitored informally through IPVAP coordinator reports. At the time of our review, we were told that national templates and a dashboard were being developed to ensure standardized data collection.
All seven VISN champions we interviewed suggested that metrics would be helpful in tracking outreach and outcomes, evaluating implementation progress, identifying staffing needs, and providing leaders with data-informed briefings. With this in mind, we recommended that the under secretary for health expedite standardized program evaluation processes to identify implementation and program deficiencies and monitor corrective actions and performance improvement plans.
Adam Roy
Another major duty of the coordinators is conducting IPV screening. The report really provided some interesting information on that. It suggested that while IPV screening isn’t required by VHA, it is something that the coordinators do. Can you talk about this?

Amber Singh
That’s right, IPV screening is not required. However, VHA encourages providers to integrate IPV screening into routine workflow and holds leaders at the medical center and VISN levels responsible to determine the frequency of screening. We found that 86 percent of respondents reported that routine IPV screening had been implemented. Among those who reported routinely screening, a third reported only screening women.
Adam Roy
So, almost 15 percent of the coordinators reported not having implemented routine screening, and of those two-thirds who did report routinely screening, did not screen both men and women. What barriers were preventing more routine screening at these medical facilities?

Amber Singh
That is really a great question. Fifteen of the 25 IPVAP coordinators we interviewed described screening as one of the most challenging aspects of IPVAP implementation. They explained to us that screening being optional and lack of staff buy-in due to other priorities in clinical care were barriers to routine screening. Some IPVAP coordinators suggested that mandatory IPV screening should be considered.

Adam Roy
Ultimately, the report made seven recommendations. Today, we’re more than six months down the road. To date, what’s the status of these recommendations? Do all remain open, and if so, what actions has VHA taken or is taking to work toward closing them?

Amber Singh
All seven recommendations remain open today, and VHA has proposed action plans with anticipated implementation later this year.

Adam Roy
Good to hear, good to hear. Amber, thank you very much for joining me today. Is there anything you want to add before we close this out?

Amber Singh
Thank you as well. I really do appreciate the opportunity to talk about this report today. It’s such an important topic. I’ll just reiterate that if you’re experiencing, or know someone who is experiencing, intimate partner violence, please reach out and contact those resources available to you. The VA has partnered with the National Domestic Violence Hotline to enhance IPV services to veterans and their families, and it is available 24/7 at 1-800-799-SAFE or 1-800-799-7233.

Adam Roy
Really great points, Dr. Singh. Again, Amber, thanks for being here. You can find this report, titled Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance, on our website.

And if you like what you heard today, check out our latest episodes of Inside Oversight and Veteran Oversight Now, both podcasts of the VA OIG. Find all OIG podcasts on major directories such as Apple, Spotify, or Google, as well as our YouTube channel at Vet Affairs OIG. Thank you for listening.

This has been an official podcast of the VA Office of Inspector General. Inside Oversight is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Please subscribe and tune in monthly to hear how our work is helping to improve the lives of veterans. Visit the website to learn more about how the VA OIG conducts meaningful independent oversight. Report potential crimes related to VA waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online, or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800-273-8255, press one and speak with a qualified responder now.