Human Trafficking Research by Ron Chambers, MD

Medical Safe Haven Expansion

An Opportunity for GME Leadership

Ron Chambers, MD, FAAFP

Program Director, DIO

Dignity Health Methodist Family Medicine Residency

Medical Director Human Trafficking Medical Safe Haven Clinic

February 24, 2022

Healthcare Interactions with HT Victims

Where Are Victims Seen

● >90% of patients seen at our center reported contact with a healthcare system while being trafficked. (Demographics include labor trafficking, cross ethnicities, genders, and languages but majority are US Citizen English speaking female sex trafficking victims).1

○ No Interventions

● 87.8% of victims interviewed in 2014, who identified as “female sex trafficking survivors” reported contact with a healthcare system.1

○ No interventions.

Healthcare Interactions with HT Victims

Where Are Victims Seen

● 77% of sexually exploited youth in Oakland, CA. reported seeing a physician regularly.1

33% currently on prescribed meds, 49% hospitalized.

***Likely lower incidence in populations which include men, foreign nationals, labor trafficking***

(Only 37% of foreign nationals in a recent small study, saw a health care provider)1

So, how prepared are we in Health Care?

Recognized the knowledge Gap

2017 Survey of Family Medicine Program Directors

Published, Robust Data

Figure 2: Journal of Human Trafficking: Assessing Family Medicine Residency Programs’ Training on Human Trafficking: A National Survey of Program DIrectors. https://doi.org/10.1080/23322705.2020.1780082

Skills

Assessed in confidence question domains:

Q1. Raising the question of human trafficking.

Q2. Understanding common indicators, signs, symptoms.

Q3. Knowledge of where to find local and national resources.

Q4. Principles and application of victim centered care.

Q5. Responsibility when physician identifies an adult versus a pediatric human trafficking victim.

Figure 4: Journal of Human Trafficking: Assessing Family Medicine Residency Programs’ Training on Human Trafficking: A National Survey of Program DIrectors. https://doi.org/10.1080/23322705.2020.1780082

Knowledge

Evaluating participants knowledge on human trafficking definition, prevalence and etiology, concepts of trauma bonding, and healthcare interactions.

Figure 5: Journal of Human Trafficking: Assessing Family Medicine Residency Programs’ Training on Human Trafficking: A National Survey of Program DIrectors. https://doi.org/10.1080/23322705.2020.1780082

Attitude

Assessed in question domains

Q1. Educational importance for resident physicians.

Q2. Understanding trauma informed care and applying to human trafficking victims.

Q3. Importance of victim-centered, trauma informed care.

Q4. Victims exposure to health care providers.

Q5. Victim-centered care concepts

Figure 6: Journal of Human Trafficking: Assessing Family Medicine Residency Programs’ Training on Human Trafficking: A National Survey of Program DIrectors.

Medical Safe Haven

Defined Medical Safe Haven: “an umbrella term used to describe clinics providing longitudinal care for patients who have experienced trafficking using validated victim-centered trauma informed care techniques and incorporating survivorinformed practices.”

Medical Safe Haven

Methodist Family Medicine Residency Clinic - Sacramento, CA

PATIENT OUTCOMES

4 Fold Increase in Program Completion Rate

Decreased Mental Health Morbidity (PTSD, Depression/SI, GAD)

Decreased Physical Health Morbidity (STIs, Substance Use Disorder, Etc.)

>15 Babies Delivered ☺

PROVIDER OUTCOMES

Paradox Effect on “Burnout”

Translation of Skillsets to Multiple Populations

Reputation as Leaders in the System

High Recruitment Value for Applicants

Integrated Care Competence

RESEARCH

Education: “TRUTH” Study

Patient Outcomes: TIC TOC Study

Medical Safe Haven Patient Visits

700+/year

Medical Research: Complex PTSD and TCA

Health System Economic: ED Utilization

REPLICATION

Internal: Primary Care Residency Dignity/CHI

1. Cheap 2. Widespread 3. Ripple

External: All Primary Care Residencies (Ex: Northwell Health)

So we started this care at the Medical Safe Haven…

But how do we know this works?

Trauma Informed Care Trafficking Outcomes “TICTOC” Study

Figure 7: Predicted probability of completing the CASH program checklist by MSH status. https://doi.org/10.1177/21501319221093119

MSH & Program Outcomes

● For each additional month of MSH participation, the odds of program completion increased by 11% (p-value<.001)

○ Average length of MSH care = 9.5 months (15 months among MSH group)

MSH & Program Outcomes

● Among MSH Patients, the odds of program completion increased by 6% for each additional appointment made (p-value<.05)

○ Both appointment arrivals and cancellations - but not “no shows”increased the odds of program completion,

Figure 9: Predicted probability of completing the program checklist by MSH appointments (MSH patients only).

MSH & Program Outcomes

Figure 10: Predicted probability of completing the CASH program. https://doi.org/10.1177/21501319221093119

https://doi.org/10.1177/21501319221093119

Figure 11: Kaplan-Meier curves for program incompletion by MSH status.

Our “Holy Grail” Study is underway…

Figure 12: Cerner Care B EHR document list type example

CommonSpirit Vision Award 2022

Academic Excellence

Mission Award

Trauma-coerced Attachment and Complex PTSD: Informed Care for Survivors of Human Trafficking

Figure 13: Journal of Human Trafficking: Trauma-coerced Attachment and Complex PTSD: Informed Care for Survivors of Human Trafficking.

What We Are Seeing. What We Are Learning.

Medications Can Be Instrumental in Recovery but Evidence Based Data is Lacking and Communication is the Key

Figure 14: Journal of Human Trafficking: Trauma-coerced Attachment and Complex PTSD: Informed Care for Survivors of Human Trafficking. https://doi.org/10.1080/23322705.2021.2012386

What We Are Seeing. What We Are Learning.

Physicians Needs More Than Concepts, We Need Concrete Logistical Frameworks for Care (Or, at least that makes us more comfortable…)

What We Are Seeing. What We Are Learning.

Physicians Needs More Than Concepts, We Need Concrete Logistical Frameworks for Care (Or, at least that makes us more comfortable…)

https://www.dignityhealth.org/content/dam/dignity-health/pdfs/sacramento/msh-physician-tip-sheet-patient-visit-21919.pdf

What We Are Seeing. What We Are Learning.

Physicians Needs More Than Concepts, We Need Concrete Logistical Frameworks for Care (Or, at least that makes us more comfortable…)

Table 16: Human Trafficking ICD-10-CM Code Categories. Retrieved from American Hospital Association. (2018, September). Fact Sheet: ICD-10CM Coding for Human Trafficking | AHA. Www.aha.org. https://www.aha.org/factsheet/2018-factsheet-icd-10-coding-human-trafficking

Current Replication Sites*

Figure 18: Medical Safe Haven Program scope of services card and site location map.

Where We Want to Go THE TAKE HOME POINTS

Create Medical Safe Havens within Primary Care Residencies

1. It is low utilization (cheap)

2. It could provide widespread care

3. In a residency clinic it concurrently trains the doctors of tomorrow to care for this vulnerable patient population (ripple effect)

CommonSpirit Can Lead the Effort!

Goal: Replicate Throughout the CommonSpirit GME System

Contact: Jennifer.Cox@CommonSpirit.org

Website Resources: DignityHealth.org/msh

Thank you.

References

1. Alexandra Zendrian. (2018, February 9). Hospital staff to identify, help human trafficking victims | Northwell Health. Www.northwell.edu.

https://www.northwell.edu/news/hospital-staff-to-identify-help-human-trafficking-victims

2. American Hospital Association. (2018, September). Fact Sheet: ICD-10-CM Coding for Human Trafficking | AHA. Www.aha.org.

https://www.aha.org/factsheet/2018-factsheet-icd-10-coding-human-trafficking

3. Chambers, R. (2017). Mercy Family Health Center-Medical Safe Haven Physician Tip Sheet: Clinic Patient Visit Physician Tip Sheet: Medical Safe

Haven Patient Visit. https://www.dignityhealth.org/content/dam/dignity-health/pdfs/sacramento/msh-physician-tip-sheet-patient-visit-21919.pdf

4. Chambers, R., Cox, J., & Gibbs, H. A. (2019). Mercy Family Health Center Human Trafficking Medical Safe Haven Program and Shared Learnings

Manual. https://www.dignityhealth.org/content/dam/dignity-health/pdfs/sacramento/sac-ht-msh-program-manual-word-97-2003-190318-new.pdf

References

5. Chambers, R., Gibson, M., Chaffin, S., Takagi, T., Nguyen, N., & Mears-Clark, T. (2022). Trauma-coerced Attachment and Complex PTSD: Informed Care for Survivors of Human Trafficking. Journal of Human Trafficking, 1–10. https://doi.org/10.1080/23322705.2021.2012386

6. Chambers, R., Greenbaum, J., Cox, J., & Galvan, T. (2022). Trauma Informed Care: Trafficking Out-Comes (TIC TOC Study). Journal of Primary Care & Community Health, 13(1-18), 215013192210931. https://doi.org/10.1177/21501319221093119

7. Laboratory to Combat Human Trafficking + HEAL Trafficking. (2018). Laboratory to Combat Human Trafficking + HEAL Trafficking HEALTH

CARE PROVIDER HUMAN TRAFFICKING TRAINING: Assessment Tool.

https://healtrafficking.org/2018/12/assessment-tool-for-health-care-provider-human-trafficking-training/

8. Mishori, R., Stolarz, K., Ravi, A., Korostyshevskiy, V. R., Chambers, R., & Cronholm, P. (2020). Assessing Family Medicine Residency Programs’ Training on Human Trafficking: A National Survey of Program Directors. Journal of Human Trafficking, 7(4), 1–13.

https://doi.org/10.1080/23322705.2020.1780082