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Program Models

Once you complete your community assessment, it is time to discuss what type of program model might work best in your community. You need to decide if your program will be hospital- or community-based, or you could create a model that combines more than one type of care setting. If you have an existing hospital-based program, you may want to expand to a mobile program or provide care at a community site. Some communities will not be able to provide 24/7 coverage. This lack of coverage should not prevent the development of a SANE program that can offer many improvements to the care received by sexual assault patients.50 The table below describes the different types of program models. It is important to realize that models can be blended or combined, and what is most important is to create a program that best meets the needs of your community.

SANE Program Models 

Type - Description  Advantages  Challenges 

Mobile Program - Nurses are employed by a single agency or hospital. They travel to some or all of the hospitals in a community to provide medical forensic examinations. 
  1. Nurses go to the patient to provide care. 
  2. Increased volume of patients can help nurses maintain competency.
  3. Law enforcement and prosecution only deal with one SANE provider. 
  4. Does not impact staffing of each emergency department.
  5. Patients who are seen in an emergency department can immediately access a higher level of medical care if needed based on their condition. 
  6. Can allow for creative employment models, including employee, independent contractor, or contracted employee.
  1. Depending on the area of the community, care may be delayed. 
  2. Nurses need to be careful about leaving confidential patient information unsecured, unless charts are immediately returned to a central location. 
  3. The program will need a memorandum of understanding with each hospital where care is given, particularly when hospitals are from multiple health systems.
  4. The program is responsible for ensuring the nurse is properly licensed, has malpractice insurance, and meets all required standards for providing care at the individual hospitals. The nurses should not have to satisfy several sets of requirements/trainings at each site.
  5. Must have a plan for when two different locations require an examiner at the same time. 
  6. There should be thorough and complete instructions for nurses about processes at each site (directions, parking location, hospital staff contact, etc.).
  7. Other logistical considerations include transportation to and from locations, insurance for use of a private vehicle, and handling/storage of evidence.
  8. Hybrid programs (fixed setting and mobile team) need to have clear guidelines for which cases require mobile team activation versus transfer to fixed location.

Hospital-Based Program - Provides medical forensic examinations in a hospital setting. This can be in the emergency department or another area of the hospital, such as labor and delivery.
  1. Facility has medical staff onsite 24/7. 
  2. Facility has the ability to provide higher levels of care for patients with other trauma or medical needs. 
  3. Hospital provides infrastructure and ancillary services such as legal counsel, medical records. 
  1. Using an emergency department is a costly way to access care that might not require the equipment and personnel. 
  2. Patient care may be delayed if other emergency department patients with more urgent medical needs are seen first.
  3. Will need an agreement about how the program will be staffed. There must be either a separate schedule for SANE shifts or a backup person who will be called in if the SANE nurse is working a regular shift in the ED and needs to do a case. 

A hospital-based child abuse team is embedded in the SANE program.
  1. SANE is part of a team that includes child abuse pediatricians or other medical providers with expertise in all forms of child abuse and neglect.
  1. Nurses will need pediatric-specific training.

Community-Based Program - Examinations are provided at the community-based location.
  1. Patients can be seen in a setting that is less medical and more private. 
  2. Lower costs for medical care by avoiding emergency department charges. 
  1. Need to provide all infrastructure for the program, including medical records storage, examination room, and examination equipment. 
  2. Need to have facility liability in addition to malpractice insurance. 
  3. Need to provide security if examinations will be provided 24/7.
  4. Need to have protocols with hospitals about how to have higher levels of care for patients.
  5. Need to have protocols with law enforcement about how patients will be transferred to the program and how evidence will be picked up or stored.

Family Justice Center Model - SANE programs are incorporated with other programs or agencies that provide services to survivors of sexual assault.
  1. Patients can be seen in a setting that is less medical and more private. 
  2. Patients can receive other types of the services that might be housed in the same setting, such as legal, advocacy, and other support services.
  3. Eliminates the need for patients to go to multiple locations to receive services. 
  1. Need to provide all infrastructure for the program, including medical records storage, examination room, and examination equipment. 
  2. Need to have facility liability in addition to malpractice insurance. 
  3. Need to provide security if examinations will be provided 24/7.
  4. Need to have protocols with hospitals and law enforcement about how patients will be transferred to the program and how evidence will be picked up or stored.

Children’s Advocacy Center Model - SANE may provide both acute and chronic examinations in this setting. 
  1. Minor patients are more likely to receive the comprehensive medical care and mental health referrals needed to address their sexual victimization and other unmet medical needs.51,52 
  2. Patients may present with law enforcement or child welfare, with a parent or caregiver, with a friend or alone.
  3. Provides a multidisciplinary approach to the investigation of child abuse.
  1. May be difficult to staff 24/7.
  2. Will need a referral source for children with injuries requiring a higher level of medical care (e.g., x-ray).

Regional/Shared Program
  1. Cost effectiveness – shared costs since many hospitals cannot afford 24/7 coverage.
  2. Patients get appropriate care with more positive outcomes.
  3. Nurses who work in hospitals without many cases have more opportunities to provide care and maintain their skill level.
  4. 24/7 coverage is provided for several hospitals.
  5. Standardized policies/protocols/documentation, paperwork, and job descriptions.
  6. Nurses maintain their skills in the care of this patient population.
  7. Nurses’ documentation skills improve through increased experience and consistent peer review.
  8. A call system can be put in place that increases coverage but decreases overall call responsibility since more nurses are available.
  1. Hospitals must get buy-in from hospital managers, administrators, human resource directors, and attorneys in signing an MOU/contract/agreement spelling out details. 
  2. Several issues must be agreed upon, including the reimbursement process; acceptance of the orientation of each respective hospital; and the willingness of forensic nurses at each hospital to participate, travel to the various hospitals, and take minimum call. 
  3. Emergency department staff must be accepting and helpful to forensic nurses who may not be familiar with the care/equipment/exam room layout, and that these nurses will not provide care to other ED patients.
  4. This model requires a paid coordinator who can oversee that competency standards are maintained, case/peer review, a call schedule, etc.
  5. Will forensic nurses be willing to take call?
  6. Set minimum call standard.

Independent Contractors - SANEs who provide care at a hospital or facility based on a written contract. 
  1. May be able to provide economical care to hospitals that have only a small number of sexual assault patients. 
  1. Storage and maintenance of medical records and evidence.
  2. Billing and payment of services.
  3. Will need to be credentialed at every facility where the SANE provides care. 
  4. Will need to arrange with another program or provider to obtain peer review. 

Facility-Specific Setting - Corrections
  1. Able to provide SANE care in a secure environment that reduces risk of injury to staff and others when transporting inmates outside of the correctional facility.
  1. Will need to provide special training to nurses about safety issues when providing care in a correctional facility. 

Military/Deployed
  1. Military personnel have access to forensic examinations, health care (medical and mental), and victim advocacy from a certified victim advocate.
  2. Sexual assault victims are given priority and treated as emergency cases. Emergency care consists of emergency medical care and the offer of a Sexual Assault Forensic Exam (SAFE).
  3. The victim is advised that even if a SAFE is declined, the victim is encouraged (but not mandated) to receive medical care, psychological care, and victim advocacy.
  4. The Sexual Assault Prevention and Response Program provides care that is gender-responsive, culturally competent, and recovery-oriented.
  1. Ensuring access to trained, certified victim advocates and Sexual Assault Medical Forensic Examiners in remote locations without a U.S. military medical facility. Department of Defense (DoD) Sexual Assault Response Coordinators and Sexual Assault Prevention and Response Victim Advocates pursue certification through the DoD Sexual Assault Advocate Certification Program.
  2. Maintaining evidence integrity and chain-of-custody when collected and when transported stateside.
  3. Maintaining patient confidentiality in a remote setting.
  4. Jurisdictional issues when in a foreign country.