OVC Support for Replicating SANE Programs
OVC has been an unwavering proponent of SANE programs. Its efforts to promote program development have focused primarily on the three projects described below. Through a competitive grant solicitation process, Dr. Linda Ledray, Director of the Sexual Assault Resource Service in Minneapolis, Minnesota, was selected by OVC to spearhead these initiatives.
SANE Development and Operation Guide
This publication, released in 1999, facilitates the development of SANE programs in communities across the country by providing comprehensive information based on the collective wisdom of those who have been operating SANE programs. The Guide includes chapters on the history and development of SANE programs, the SANE program model, community approaches to sexual assault response, assessing the feasibility of a SANE program, funding information, program implementation, staffing information, training needs, program coverage and operation, pediatric SANE exams, policies and procedures, and maintaining a healthy program. The Guide offers invaluable detailed information not available from any other single source to those interested in starting a SANE program.
The Sexual Assault Resource Service (SARS) Web site at www.sane-sart.com offers information and technical assistance to individuals and institutions interested in developing new SANE programs and improving existing ones. The goal of the Web site is to facilitate communication among SANE programs and provide them with resources to help them overcome obstacles. Features include a live chatroom (under construction), an online version of the SANE Development and Operation Guide that can be viewed or downloaded, information on upcoming related conferences and training programs, and information about starting a SANE program.
SANE programs can register at the Web site at no cost. If programs agree to provide case information, Web site staff will provide them with program data analysis and comparison data from other registered programs. Ledray is particularly interested in data collection on drug-facilitated sexual assaults.43 By using the data collected through the Web site, she hopes to obtain a better estimate of the occurrence of suspected and confirmed drug-facilitated sexual assaults, in addition to data for the estimated timeframe for SANE collection of a urine specimen and results of the drug analysis.
To supplement the technical assistance available through the Guide and the Web site, OVC grant funding supported a series of regional workshops during 1998 and 1999 to SARTs interested in developing SANE programs. Ledray, Project Director, trained SARTs from at least three localities at each regional workshop. The workshops' purpose was to help SARTs evaluate the feasibility of a SANE program in their region, to consider how to develop a program that suits the needs of their community, and to brainstorm how to overcome obstacles. These workshops helped SARTs save time, money, and energy that otherwise would have been spent seeking out information and advice. Ultimately, the workshops can help regions more rapidly develop and implement successful SANE programs.
Since grant funding for these workshops has ended, OVC's Training and Technical Assistance Center (TTAC) will continue to assess community interest in developing SANE programs and will offer additional regional training and technical assistance. Contact information for TTAC is available in the Resources section of this bulletin.
Standards, Training, and Certification
Communities interested in starting a SANE program can benefit from the experiences of pioneers in the field who recognized the importance of providing quality medical care and forensic evaluation to every sexual assault victim, no matter the place, time, or circumstance. Based on their early experiences, standards of practice, training curricula, and training and certification requirements have developed.
Standards of Practice
Standards of practice have emerged to ensure that SANEs respond to the medical-legal needs of victims in a consistent and appropriate fashion. The SANE Council of IAFN adopted the first SANE Standards of Practice in 1996. Several states have or are in the process of developing state-specific SANE standards. For example, the Virginia State Council of Forensic Nurses created Standards of Practice for SANEs in 1997. These standards are based on the IAFN standards but address state policies and standards relevant to the operation of SANE programs in Virginia. Since there is no regulatory body for enforcement, programs are asked to voluntarily adhere to the standards.44
Other states have incorporated SANE response into broad standards for the provision of comprehensive services to sexual assault victims. In New Jersey, for example, a multidisciplinary council coordinated through the Office of the Attorney General released Standards for Providing Services to Survivors of Sexual Assault in 1998. The protocols are geared to improve provision of information and services to victims; encourage coordination among service providers; enhance the collection, preservation, and transmission of forensic evidence; and contribute to the prosecution of sex crimes. The protocols recommended the development of standardized training and state standards for SANEs and SARTs and a certification process for SANEs in every county.45
Training and Certification
SANEs require specialized training. Basic training programs typically consist of at least 40 hours of classroom instruction. Topics can include the definition of the SANE role, collection of evidence, testing and treatment of STDs, evaluation of other care needed, victim responses and crisis intervention, assessment of injuries, documentation, courtroom testimony, corroborating with community agencies, competent completion of an exam, and forensic photography.46 Some programs also specify a designated number of clinical hours to build SANE experience. Continuing education and competency requirements should be routinely met to maintain active SANE status.
IAFN recently published the SANE Education Guidelines to serve as a framework for the specialized training and education of SANEs. The document set forth a minimum level of required instruction. To further ensure consistency in practice and credibility in the courtroom, IAFN is also working to establish a national-level certification for SANEs. In the meantime, several states have developed state-level training programs and certification criteria.
In 1997, the Texas legislature passed a bill directing the Sexual Assault Prevention and Crisis Services Division of the state attorney general's office to adopt rules establishing minimum standards for SANE certification. Certification rules were not part of the bill and can be revised without legislative approval. Certification addresses "currency of practice," meaning the formal process by which training and continuing education and the number of exams performed per year by a SANE are documented. Nurses can seek adult and/or pediatric certification. Several prosecutors have asked their local SANEs how they can help them get certified, since it will further validate SANEs' education and currency of practice in court. A 56-hour SANE training, based on certification rules, is offered at no cost to local multidisciplinary teams willing to make the commitment to start a SANE program. Nurses are expected to complete clinical hours and to begin program operation within 8 months of classroom training.47
The Colorado Coalition Against Sexual Assault (CCASA) offers a 48-hour SANE training to nurses from communities in the state willing to develop a SANE site. Nurses are asked to contribute $200 toward the training. Interested organizations or communities are asked to apply for training and provide victim-centered care in accordance with clinical and operational standards that have been developed by a multidisciplinary SANE advisory board. The CCASA SANE coordinator will also provide ongoing technical assistance to the sites (e.g., conducting site visits, providing ongoing education, developing evaluation tools, and facilitating networking among SANE programs).48
The Wisconsin Coalition Against Sexual Assault is offering free SANE training in various regions of the state. Faculty members come from several Wisconsin SANE programs. Participation requires commitment by the sponsoring hospital or facility to start a SANE program.49
One of the basic decisions in establishing a new program is determining where it will be located. Considerations for site selection include safety and security for victims and staff, physical and psychological comfort of the victim, access to medical support services that provide care of injuries, access to a pharmacy or medication, access to laboratory services, and access to necessary supplies and equipment to complete an exam.50 Rather than basing location decisions on what is convenient for service providers, SANE program planners should develop sites that meet the needs of victims in their community. Addressing victim needs also requires that, regardless of the location of the program site, SANEs communicate and coordinate their efforts with others involved in the community response system (e.g., through active participation in sexual assault response teams).
Hospital-Based Exam Sites
The majority of SANE exam sites are located in hospital emergency departments. The emergency department offers a secure site, is open 24 hours a day, and provides access to a wide array of medical and support services.51 Physicians are available to treat victim injuries, and SANEs can conduct evidentiary exams and treat victims for STDs at the same location. Emergency department overhead and physician fees, however, can represent a sizable sum charged to victims, their insurance, SANE programs, or state compensation programs.52 To control these costs, some SANE programs have negotiated reasonable fees for use of the emergency department and the department's staff time.53
The SANE program in Madison, Wisconsin, recently became a hospital- based program. The program was moved from the local YWCA to an office in the hospital emergency department where exams were already being performed. While the SANE program is still expected to seek outside funding, Coordinator Jill Poarch hopes that locating in the hospital will offer her program more financial security, a better clinical fit, and easier access to exam supplies and equipment.54
SANE programs, like the one in Tulsa, Oklahoma, have opted to locate in hospital-based clinics designed specifically for sexual assault victims that are in close proximity to the emergency department for urgent care and other hospital services. If victims in Tulsa do not require emergency department treatment, they generally do not have to register as hospital patients.55
Other SANE programs perform exams at more than one hospital as well as in places other than hospitals including health departments, women's clinics, and morgues (in cases where the victim is deceased). SANEs may also conduct suspect exams at law enforcement agencies or jails. The SANEs in Minneapolis, Minnesota, go to eight local hospitals.56 The SANE Program in Middlesex County, New Jersey, is based out of the county Health Department and uses public health nurses who are SANE trained.57 Nurses from the Monmouth County, New Jersey, SANE Program conduct forensic examinations at three local hospital emergency departments. These three hospitals agreed to have expedited registration for sexual assault victims, private waiting areas, and exam rooms stocked with the necessary equipment and supplies.58
Numerous programs that do hospital exams base their administrative offices at sites other than hospitals. The Monmouth County SANE program office is located in the prosecutor's office.59 The Minneapolis program office is in a health center.60 The Tulsa SANE program office is based in the police department.61
Those interested in starting hospital-based SANE sites should recognize that some hospitals may be reluctant to support such a program. For example, emergency department staff may be uncomfortable with the idea of working collaboratively with SANEs and allowing them to use their resources, particularly if SANEs are not hospital employees. To overcome resistance, planners can establish dialogue with hospital administrators and emergency department physicians and nurses to explain the benefits of SANE programs, to identify potential problems, and to take action to resolve them. (See also the Funding Issues section of this bulletin for a discussion on building hospital financial support.)
Community-Based Exam Sites
Community-based programs typically offer victims more privacy than hospital exam sites and are not mandated to report felony crimes as hospitals are required to do in some states.62 Victims are usually not billed for medical care and services. A community-based program may be more committed to coordinating service provision with other members of the response team. For example, some SANE programs may be one component of a comprehensive response center for sexual assault victims.
The Sexual Assault Resource Center in Memphis, Tennessee, is a community-based program. It employs SANEs, legal advocates, and counselors. SANEs conduct forensic examinations. Legal advocates assist victims who are involved in the criminal justice system. Regardless of whether victims report the assaults to the police, counselors offer short- and long-term counseling. The Memphis Police Department lab is also located on the center's premises. All center staff members participate in weekly meetings to review cases.63
Community-based programs, however, must tackle several difficult issues during the implementation process. Program developers should ensure that individuals with clinical backgrounds, preferably SANEs, administer their programs. They need to work with area hospital emergency departments to create protocols around timely evaluation and treatment of victim injuries and for medication standing orders. Developers need to consider whether resources and budgets are sufficient to support their SANE programs. Developers also must confer with prosecutors to determine whether forensic evidence and SANE testimony could be perceived as being biased because of the location of the program and then must determine how to overcome this problem.
Val Sievers, SANE Coordinator for the Colorado Coalition Against Sexual Assault, noted that the SANE site requirements and practice standards typically have not been difficult for most hospital-based programs to apply. Hospitals function in accordance with standards of practice and have existing mechanisms for quality improvement, continuing education, and protocol development. In addition, hospital organizations that employ nurses have an understanding of professional licensure and scope of practice. Applying clinical and practice standards is often more challenging for community-based programs, which historically have not worked with licensed registered nurses and are not familiar with issues that influence nursing practice. In order for community-based programs to be successful, Sievers encourages them to work with nurses in their area to ensure that clinical issues are addressed.64
The Grand Rapids, Michigan, SANE program is administratively and clinically located in a suite of rooms at the YWCA sexual assault advocacy center. To ensure that all sexual assault victims who go to local hospitals are offered SANE services, the SANE program developed a triage protocol with the hospitals and negotiated with two facilities to allow SANEs to do exams in their emergency departments in cases where victims sustain serious injuries.65
Funding is another important issue to address when considering the feasibility of a SANE program. Existing SANE programs demonstrate that it is possible to obtain needed funding with a sufficient commitment of time, research, fundraising, and creativity. Like many sexual assault crisis centers, SANE programs often must seek out a variety of funding sources to support their work. The sooner a SANE planning team begins to think about how it will cover program startup and ongoing operational costs, the quicker it can seek out assistance from potential partners and funders.
In 1997, a pilot SANE program and SART were implemented in Monmouth County, New Jersey, by the state attorney general's office.66 The pilot provided an affordable way to introduce SANEs, evaluate benefits and obstacles, and create a model for statewide duplication.
SANE program startup costs include community and institutional needs assessments, facilities and utilities, office and exam supplies and equipment, staff advertising and selection, staff training, media promotion, and staff salaries for the first year.67 Planning teams should be careful in estimating how many trained SANEs are needed to ensure that the program has the capacity to consistently and promptly respond to incoming calls on a 24-hour basis. Otherwise, the program will fail to significantly reduce medical-legal response time to sexual assaults.
Beyond the issue of securing funds for initial expenses, it is critical that planners also consider how the program will be sustained financially over the long term. Stable funding will allow SANE program coordinators to spend more time on day-to-day clinical operations and less time obtaining grants and donations.
The local medical community is an obvious place to begin seeking financial support. Hospitals may be willing to donate space, supplies, and equipment and to help cover operating costs. Some hospital administrators, however, may be reluctant to develop new programs that they perceive will increase their costs and decrease profits. SANE program planners can help administrators understand how such a program can enhance hospital services in a more cost-effective manner. Part of this task involves revealing the hidden costs involved in treating sexual assault victims in the emergency department without a SANE program. Indirect and overhead costs include physician and nursing time to do the exam and testify in court, supplies, and staff training. It is also important to highlight the less tangible benefits of SANE programs. Planners should stress that not only do SANEs provide quality, patient-centered care, their services often enhance the hospital's reputation, allowing it to stand out among other local medical facilities. SANEs are also invaluable resources for hospital community outreach and education initiatives.68
In 1996, The Urban Institute visited 12 states as part of its study of the STOP (Services*Training*Officers*Prosecutors) grant implementation process. It reported that forensic exams cost hospitals about $800 when a physician conducts the exam and between $200 and $300 when a trained nurse, such as a SANE, conducts it.69
Reimbursement for Services
Some SANE programs operate on fee-for-service reimbursement from the hospitals served, police department, or county prosecutor's office. They, or the hospital they contract with, are reimbursed for costs associated with forensic exams through funding from state victim compensation programs, funded partially through the federal Victims of Crime Act (VOCA). Reimbursement varies tremendously from state to state. It is often limited to a set maximum dollar amount for each exam completed, ranging from as little as $50 per exam to $750 or more per exam. Compensation to the SANE program for exams often does not cover the majority of costs. Reimbursement gets complicated because only part of the procedure is forensicit also entails medical components. Some states pay for evidence collection but not followup medical care.70
Victim Assistance Funds
SANE programs are also encouraged to apply for state VOCA victim assistance grants. In making the decision about whether to fund SANE programs, state VOCA administrators should recognize that SANE programs address critical medical-legal needs of sexual assault victims. Federal final program guidelines for the VOCA Assistance Grant Program permit the use of these funds to purchase colposcopes, and several states have approved requests to purchase colposcopes using VOCA funds. For more information about VOCA funds, visit the OVC Web site at www.ojp.usdoj.gov/ovc.
Other Justice Department Resources
SANE programs may also be able to obtain funding through other U.S. Department of Justice grant projects, such as STOP grants of the Violence Against Women Act (VAWA) and the Edward Byrne Formula Grant Program. Call the U.S. Department of Justice Response Center at 18004216770 to be placed on their mailing lists to receive updated information on funding resources for violence against women programs.
Other Funding Sources
In addition to the U.S. Department of Justice, there is the potential for funding from other federal and state agencies, private foundations, community foundations, grant-making public charities, individual donors, and fundraising campaigns. The Foundation Center provides a wide array of information on grant funding resources through its library holdings, publications, and online services. Visit its Web site at www.fdncenter.org.
Local hospitals may be willing to assume SANE program costs that exceed reimbursement for services from grants and donations, especially if the hospital administration understands that it is already assuming hidden costs associated with treating victims in a less efficient manner without SANEs. Community-based programs may have more difficulty absorbing costs because of limited resources and budgets.