Expanding Virtual Care Access for Sexual Assault Survivors in Texas

A troublingly common form of violence in the United States, sexual assault drives the need for easier access to physical and mental healthcare. As modes of virtual care become increasingly integrated into the US healthcare system, some healthcare providers are implementing telehealth to enhance care for sexual assault survivors.

The statistics are staggering. Over half of women and about 33 percent of men have experienced sexual violence during their lifetimes, according to the Centers for Disease Control and Prevention.

Most sexual assault survivors (70 percent) experience moderate to severe distress, and 94 percent of women who are raped experience symptoms of post-traumatic stress disorder (PTSD) during the two weeks following the incident, data from the Rape, Abuse & Incest National Network (RAINN) shows. Additionally, sexual assault survivors are at risk of pregnancy and sexually transmitted infections.

To better support survivors of sexual assault and expand access to needed healthcare services, Texas A&M University's board of regents launched the Texas A&M Health Center of Excellence in Forensic Nursing in 2019.

The decision to launch the center came after the university won two grants, said Stacey Mitchell, DNP, clinical professor and director of the Texas A&M Health Center of Excellence in Forensic Nursing, in an interview. One grant from the Health Resources Services Administration aimed at increasing the number of forensic nurses, and the other, from the Office for Victims of Crime, was focused on setting up a telehealth program.

"This was pre-COVID, and we were already exploring telehealth, and how we could put telehealth equipment and connect expert forensic nurses to rural hospitals and our critical access hospitals to help guide the medical forensic exam for sexual assault," she said.

Telehealth has played a critical role in expanding access to healthcare before and during the COVID-19 pandemic, particularly for underserved communities. For instance, a study published last year shows that telehealth helped increase appointment completion rates in rural areas by about 20 percent.

The Texas A&M Health Center of Excellence in Forensic Nursing uses telehealth to expand access to trauma-informed care for sexual assault survivors in two ways. Through its Texas Teleforensic Remote Assistance Center (Tex-TRAC), the center virtually connects rural and critical access hospitals in Texas with sexual assault nurse examiners (SANEs) to provide forensic examinations following sexual assault. These nurses, who are available 24 hours a day, guide clinicians on the ground as they conduct the exams.

Then, last month, the center launched the Texas A&M Assessment and Care for Trauma Survivors (ACTS) Clinic, which connects sexual assault survivors and advanced practice registered nurses through telehealth for follow-up care. It is open to residents 18 and older across Texas.

State residents who have been sexually assaulted can be referred to the clinic by clinicians who examine them in the community or through Tex-TRAC, Mitchell explained. Through the ACTS Clinic, nurses can conduct a virtual exam to check on wounds and discuss other ongoing issues patients may be dealing with. They can also make referrals for other services, such as laboratory testing in the community and mental healthcare through its partnership with the Texas A&M Health Telebehavioral Care program.

"Then, the advanced practice nurse will receive the results, and they'll schedule a follow-up meeting or reach out electronically to the patient to give them their results and [let them know] if there's any further treatment necessary," Mitchell added.

Two advanced practice nurses are currently staffing the virtual clinic on different days. As demand for clinic services solidifies, the center may add more.

The primary reason for launching the virtual clinic is that many survivors of sexual assault do not follow up on their initial medical visit, resulting in a gap in access to needed physical and mental healthcare.

Telehealth has already proven useful in conducting follow-ups. Survey data released earlier this year reveals that follow-up care is the most common use case for telehealth, with an overwhelming majority (92 percent) of the 1,200 physicians polled saying they used telehealth for this type of care. Other research has shown that telehealth improved access to follow-up care for minority racial groups.

Mitchell and the ACTS team aim to use telehealth for that very reason.

"Follow-up care in sexual assault is traditionally very low," Mitchell. "And we were hoping, and it's still our belief, that having this service available virtually will help people feel more comfortable talking to a provider who is trauma-informed, who understands the medical needs that a survivor of sexual assault has and can provide that care."

A reason for low follow-up care rates is the lack of access to trauma-informed clinicians, like SANEs, in rural areas. According to a study published in April, sexual assault survivors seeking care in urban regions are more likely to be supported by a SANE than those in rural areas. The presence of SANEs was associated with higher rates of trauma-informed staff behaviors.

The virtual clinic also allows sexual assault survivors to access follow-up care from their own homes, where they likely have more comfort and privacy, which could help further boost follow-up visit rates, Mitchell added.

But there were hurdles to launching the clinic. According to Mitchell, finding the right people who understood the medical and emotional needs of sexual assault survivors and could communicate in a trauma-informed manner was a challenge, as was ensuring patients had access to the technology needed to participate in virtual care.

"Then, there's always connectivity," she said. "Anytime there's technology, particularly telehealth, you have to worry about connectivity. Most of Texas is very rural, and so connectivity is a real issue. We really haven't had the need to address that quite yet, but we are working on what would our plan be if the patient can't connect."

Another challenge was the credentialing process for advanced practice nurses. The time-consuming process requires filling in large volumes of paperwork, so patience is key, Mitchell noted.

As the clinic ramps up, the ACTS team hopes to break down the barriers facing sexual assault survivors seeking healthcare in Texas. By offering virtual access to clinicians with expertise in caring for sexual assault survivors, including trauma counselors, the clinic aims to expand its reach throughout the state.

"We hope to be busy," Mitchell said. "Our goal is to be busy. We want to make sure that anyone who wants access to follow-up care after their sexual assault exam and visit has that... We want to make sure that we get the word out to all of our healthcare entities and partners, our forensic nursing partners, so that they're like, 'Yes, go to this clinic.' 'This clinic is here; it's available to you.'"

Editor's note: A previous version of this article mistakenly referred to the Office for Victims of Crime as the Office for Survivors of Crime.