Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Title Page Human Trafficking and HIPAA: What the health care professional needs to know Clydette Powell, MD, MPH, FAAP [The George Washington University School of Medicine and Health Sciences] Michelle Asbill, M.S.W. [University of Illinois Urbana-Champaign] Samantha Brew, [George Washington University] Hanni Stoklosa*, MD, MPH [Harvard  Medical  School,  Brigham  and  Women’s  Hospital,   Boston MA] *Corresponding author: 75 Francis St, Boston MA 02115 hstoklosa@partners.org Main Document 1 2 3 Trafficking and HIPAA 4 5 Acronyms: 6 7 CPS Child Protective Services 8 9 DHHS Department of Health and Human Services 10 11 12 ED emergency department 13 14 EMS Emergency Medical Services 15 16 17 HCP health care professional 18 19 HIPAA Health Insurance Portability and Accountability Act 20 21 22 HT human trafficking 23 24 LE law enforcement 25 26 NHTH National Human Trafficking Hotline 27 28 29 PHI protected health information 30 31 US United States 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 12 2 3 Trafficking and HIPAA 4 5 Introduction 6 7 As health care professionals (HCPs) become increasingly aware of human trafficking 8 9 (HT) and recognize their role as first responders, they are sometimes thrust into a position at the 10 11 12 intersection of health and law. HCPs who work in emergency departments (ED), urgent care 13 14 centers, reproductive health clinics, and community health centers may be the first to encounter a 15 16 17 patient whom they suspect of being trafficked (Chang, Lee, Park, Sy, & Quach, 2015; Chisolm- 18 19 Straker et al., 2016; Gibbons & Stoklosa, 2016; Lederer, & Wetzel, 2014;). Recent literature 20 21 22 indicates that HCPs have a role to play, but some are reluctant to become engaged (Beck et al., 23 24 2015; Becker & Bechtel, 2015; CdeBaca & Sigmon, 2014; Grace, Ahn, & Konstantopoulos, 25 26 2014; Grace et al., 2014). One reason may be a lack of clarity about matters related to patient 27 28 29 privacy as delineated by the Health Insurance Portability and Accountability Act (HIPAA). 30 31 This paper lays out key questions and answers, as well as a simple algorithm, to assist the 32 33 34 United States (US) based HCP in caring for trafficked patients while complying with HIPAA.1 35 36 Specifically, it is written for  HCPs  who  are  recognized  as  “covered  entities”  by  HIPAA  (Centers 37 38 39 for Medicare and Medicaid Services, 2013). We recognize that state and federal laws change 40 41 over time. This article is not meant to substitute for formal legal advice. Furthermore, we limit 42 43 our discussion of mandated reporting to its relationship with HIPAA. To our knowledge, this is 44 45 46 the first paper to address HIPAA privacy concerns in relation to HCP referral and reporting on 47 48 suspected cases of HT. 49 50 51 52 53 Case Scenarios 54 55 56 57 58 1 As experts in health and human trafficking, we consulted with medico-legal HT experts to confirm that our 59 application and framing of HIPAA was accurate. 60 61 62 63 64 65 13 2 3 Trafficking and HIPAA 4 5 The following scenarios illustrate four different potential human trafficking clinical 6 7 encounters. At the end of this paper, the cases are discussed briefly in the context of HIPAA and 8 9 suggested responses are presented. 10 11 12 Case 1: Mandatory reporting 13 14 A 15-year old female is brought to a community health center by her parents for 15 16 17 evaluation of pelvic pain. Human trafficking of minors falls under mandated reporting 18 19 requirements for HCPs in this state. The HCP interviews her without her parents present. The 20 21 22 HCP first discusses the limits of confidentiality with the patient before starting a conversation 23 24 that might lead to a disclosure. The patient eventually discloses that she has had more than 20 25 26 sexual partners, typically does not use condoms, and has a change in her vaginal discharge. Upon 27 28 29 further discussion, she shares that, for the last three months, she has been forced by a gang to 30 31 engage in sex acts at a nearby motel every Friday night. Her parents have no idea and think she 32 33 34 just stays out late on weekends. The patient tests positive for gonorrhea and chlamydia. The 35 36 patient does NOT want her exploitation reported since her parents would be mortified and the 37 38 39 gang may retaliate. 40 41 Case 2: Disclosing protected health information (PHI) with permission 42 43 A 25-year old female is brought into the ED by her cousin and has a deep laceration on 44 45 46 her left palm. The patient is originally from Guatemala and has a limited vocabulary in English. 47 48 She is living with her cousin here in the US while applying for US citizenship. Additional 49 50 51 history obtained from the cousin reveals that the laceration occurred while the patient was 52 53 preparing dinner. The nurse notices bruising on the upper arms and recognizes the need to 54 55 56 interview the patient alone about possible physical abuse and/or labor trafficking. Ultimately, the 57 58 patient discloses that she is in a dangerous situation, which includes elements of labor and sex 59 60 61 62 63 64 65 14 2 3 Trafficking and HIPAA 4 5 trafficking and asks for help to leave her situation. She agrees to allow the HCP to speak with 6 7 community-based service providers outside the hospital in order to coordinate her care. 8 9 Case 3: Need for guidance in caring for a potential victim of HT 10 11 12 A 34-year old male presents to the ED with a chief complaint of arm pain. He speaks 13 14 Cape Verdean creole primarily. On history, and states that he fell down the stairs but is reluctant 15 16 17 to provide further details. He is accompanied by a female who offers to translate. On 18 19 musculoskeletal exam, his left upper arm appears deformed. On skin exam, he has bruises in 20 21 22 multiples stages of healing. The HCP is concerned that there may be physical abuse and/or 23 24 human trafficking, however because the health facility has no HT protocol in place it is unclear 25 26 what next steps to take, including what screening questions to ask. 27 28 29 Case 4: Disclosing PHI without consent, due to imminent threat to safety 30 31 A 19-year old male is brought in by ambulance at 3am by Emergency Medical Services 32 33 34 (EMS). The EMS provider states that the patient called 911 because he was being threatened. 35 36 The paramedic also states that a vehicle followed the ambulance to the hospital. On exam, the 37 38 39 patient is confused, and seems to be under the influence of a substance. He is dressed in tight 40 41 fitting clothing. He shares that “Derek”  said  he  was  going  to  put  a  “crack in his skull” because he 42 43 did not bring home enough money last night from a “date.” Hospital security personnel alert the 44 45 46 HCP to the fact that there is a man who keeps coming to the front of the ED inquiring about the 47 48 patient’s  whereabouts and making threats. Security is visibly fearful of this man. 49 50 51 HIPAA Overview 52 53 The following section provides, in a question-and-answer format, some of the HIPAA 54 55 56 basics, followed by the resolution of the case scenarios presented. 57 58 Question: What is HIPAA? 59 60 61 62 63 64 65 15 2 3 Trafficking and HIPAA 4 5 Answer: According to the guide from the US Department of Health and Human Services 6 7 (DHHS), HIPAA, implemented in  1996,  introduced  the  “Privacy  Rule”  as  a  means  to  provide 8 9 protection and standards for the use and release of patient information (DHHS, n.d.(a)). The goal 10 11 12 was to design a flexible policy framework that would guard patient information, but allow and 13 14 define specific instances and procedures where disclosure would be necessary (DHHS, n.d.(a)). 15 16 17 Question: Which entities must comply with HIPAA? 18 19 Answer: HIPAA  uses  the  term  “covered  entities”  to  describe  who  must  comply  with  HIPAA.   20 21 22 “Covered  entities”  include  most HCPs  (referred  to  as  “health  care  providers”  in  the  HIPAA   23 24 policy),  health  plans  and  “healthcare  clearinghouses”  (such  as  billing  or  management  companies 25 26 using health information). The Centers for Medicare and Medicaid (2013) provide an online tool 27 28 29 for determining covered entity status. In addition, subsequent to passage of the Health 30 31 Information Technology for Enforcement and Clinical Health Act of  2009,  “business associates”, 32 33 34 which provide services to or for the benefit of covered entities, are also directly subject to 35 36 HIPAA compliance and reporting requirements with respect to the PHI they come into contact 37 38 39 with when providing those services. If a HCP is not a HIPAA covered entity or the business 40 41 associate of a covered entity, the HCP is not subject to HIPAA in relation to disclosures of PHI. 42 43 44 Question: What is protected health information (PHI)? 45 46 Answer: HIPAA defines  PHI  as  “individually  identifiable  health  information,”  which  “identifies   47 48 the individual or for which there is a reasonable basis to believe can be used to identify the 49 50 51 individual” (name, birthdate) and includes certain demographic information concerning medical 52 53 conditions (past, present, and future), the dates of medical care provision, and information 54 55 56 related to the payment of rendered care (DHHS, n.d. (a), p. 3; DHHS, 2013a). 57 58 Question: When is a PHI disclosure permitted? 59 60 61 62 63 64 65 16 2 3 Trafficking and HIPAA 4 5 Answer: HIPAA instructs that a disclosure of PHI is only permitted 6 7 a) when the HCP receives permission from the individuals or their personal 8 9 representative (as defined by HIPAA) or 10 11 12 b) in circumstances specifically defined by HIPAA that require or allow for disclosure, 13 14 each of which is further defined and explained by HIPAA (DHHS, n.d. (a), p. 4-5). 15 16 17 Below, we elaborate on these permitted disclosures as they relate to HT and HIPAA. 18 19 HIPAA Operationalized 20 21 22 Question: Is a HCP, covered by HIPAA, permitted to disclose PHI in the case of a suspected 23 24 HT victim? 25 26 Answer: Yes, the HCP, covered by HIPAA, is permitted to disclose PHI in the case of a 27 28 29 suspected HT victim under the following conditions: 30 31 a) with  the  patient’s  permission or 32 33 34 b) if the patient does not give permission, then reporting is only permitted under specific 35 36 exclusions or exemptions defined by HIPAA: 37 38 39 1) Mandated reporting: HIPAA allows reporting if state law specifically mandates 40 41 a disclosure for suspected trafficking of a minor, such as in Colorado or 42 43 Massachusetts (see mandatory reporting question) or where HT falls under child 44 45 46 abuse mandated reporting laws (Atkinson, Curnin, & Hanson, 2016). When such 47 48 reporting is mandated, the reporting must be made only to the legal entity 49 50 51 authorized to receive these reports, and should include a disclosure of only the 52 53 information required under mandated reporting laws. 54 55 56 2) Imminent danger of patient or staff: The HCP is directed to make decisions in 57 58 “good  faith” and may disclose PHI when “it is felt to be necessary to prevent or 59 60 61 62 63 64 65 17 2 3 Trafficking and HIPAA 4 5 lessen a serious and imminent threat to the health or safety of a person or the 6 7 public” (DHHS, 2013b). 8 9 Question: When should HCPs get consent from patients when disclosing PHI? 10 11 12 Answer: If disclosure of PHI is not mandated by law or otherwise permitted by HIPAA as 13 14 described above, the HCP must ask the patient for consent to disclose PHI. This is true if the 15 16 17 HCP is disclosing PHI when speaking with anti-HT service providers or trying to access legal, 18 19 housing, and law enforcement (LE) resources for the patient, such as calling the National Human 20 21 22 Trafficking Hotline (NHTH). The consent is ideally in the form of written authorization, but may 23 24 be in verbal form, and should be documented in the medical record (DHHS, n.d. (b)). 25 26 27 HIPAA and Mandated Reporting 28 29 Question: Under what kinds of “mandatory reporting” state laws does HT fall? 30 31 Answer: Some state laws specifically require HCPs to report suspected cases of HT of minors, 32 33 34 but all fifty states and the District of Columbia have mandatory reporting laws requiring HCPs 35 36 to report child abuse and neglect. However, in a limited number of states, under certain 37 38 39 circumstances, the HT of minors may not be considered a form of child abuse and trafficking of 40 41 minors may not be reportable (Atkinson, Curnin, & Hanson, 2016). Shared Hope International 42 43 provides a list indicating which states have sexual exploitation in their child abuse and neglect 44 45 46 laws (Shared Hope International, 2014). Conversely, in the state of Massachusetts, for example, 47 48 HT of children is explicitly mentioned as a mandated reporting requirement under child abuse 49 50 51 statutes (189th General Court of the Commonwealth of Massachusetts, n.d.). Of note, mandated 52 53 reporting laws are controversial, and some National Academy of Medicine experts caution that 54 55 56 “adopting  a  universal  reporting  requirement  without ensuring the adequate preparation of child 57 58 59 60 61 62 63 64 65 18 2 3 Trafficking and HIPAA 4 5 welfare agencies may have unintended consequences that are harmful to the vulnerable children 6 7 that  the  laws  are  designed  to  assist”  (2013, p. 182). 8 9 Case Resolutions 10 11 12 General Principles 13 14 When a HCP suspects a patient is a HT victim, the core of the approach should be 15 16 17 patient-centered and trauma-informed. A trauma-informed interviewer and a professional 18 19 interpreter, when English is not the first language, should be drawn into the process if at all 20 21 22 possible, and the patient interviewed alone. The patient should be informed of the limits of 23 24 confidentiality prior to the interview. Multidisciplinary care for a victim of HT should be guided 25 26 by  the  patient’s  stated  needs, state laws, and will likely take many forms, including medical and 27 28 29 mental health care, connection with shelter, substance use disorder treatment, etc. (see Figure 1 30 31 for possible paths). Each of the cases below illustrates the importance of having a healthcare 32 33 34 system wide response protocol in place that standardizes and tailors this care (Baldwin, Barrows, 35 36 Stoklosa, 2017; Chang et al., 2015; Stoklosa, Dawson, Williams-Oni, & Rothman, 2016; 37 38 39 Stoklosa, Showalter, Melnick, & Rothman, 2016) (see Figure 2). 40 41 Case 1: Mandatory reporting 42 43 This case takes place in a US state where human trafficking of those under the age of 18 44 45 46 falls under mandated reporting requirements. It is implied that the parents will find out. It is 47 48 recommended that the HCP talk at length with the patient to explain what needs to be done, and 49 50 51 volunteer to help her tell her parents (e.g., offer to be in the room, and even offer to tell the 52 53 parents, if that is what she wants). Moreover, the HCP should have a long discussion with the 54 55 56 parents, emphasizing  the  child’s  victim  status  (she  is  not  to  blame)  and  the  need  for  the  parents to 57 58 59 60 61 62 63 64 65 19 2 3 Trafficking and HIPAA 4 5 support and protect her. The HCP should ask if the patient wants to be present when the 6 7 authorities are called, so she can tell them what she thinks they need to know. 8 9 Depending on state law, reporting may be made to Child Protective Services (CPS) 10 11 12 and/or LE. According to HIPAA, the report should include a disclosure of only the information 13 14 required under mandated reporting laws. Note, it is important, where possible, to work with CPS 15 16 17 and LE staff that have been trained specifically on trafficking because of the unique needs of this 18 19 population and the potential for unintended harm to the patient by untrained CPS or LE staff. 20 21 22 The National Human Trafficking Hotline (NHTH) may be helpful in identifying trained CPS or 23 24 LE staff. Through grants from the US DHHS, the 24/7/365 hotline (1-888-373-7888), is 25 26 available in over 200 languages, for any caller who needs information and guidance on matters 27 28 29 concerning HT. Because of the concerns for safety related to potential gang retaliation, 30 31 regardless of mandated reporting, referral to LE may be considered as a part of safety planning. 32 33 34 The  HCP  should  emphasize  to  LE  the  child’s  fear  of  gang  retaliation  and  the  special need for 35 36 safety measures. 37 38 39 The question arises about what to do in the rare circumstance when caring for a child who 40 41 is being trafficked and the state does NOT require mandatory reporting. In these scenarios, just 42 43 as in caring for adult victims of trafficking, a clinician should connect the patient with the 44 45 46 multidisciplinary resources that best match his/her stated needs and are most likely to improve 47 48 his/her safety and health. 49 50 51 Case 2: Disclosing PHI with permission 52 53 This  patient’s  story  raises concerns for trafficking, signals  the  patient’s  request for help, 54 55 56 and illustrates how protected health information (PHI) can be disclosed with the  patient’s   57 58 permission. The consent is ideally in the form of written authorization, but may be in verbal 59 60 61 62 63 64 65 1 10 2 3 Trafficking and HIPAA 4 5 form, and should be documented in the medical record (DHHS, n.d. (b)). Depending on the 6 7 patient’s  goals and existing HT health system protocols, the response may first include utilizing 8 9 social workers and/or contacting the National Human Trafficking Hotline (NHTH) in order to 10 11 12 identify local non-governmental organizations that could provide resources such as housing, 13 14 substance use disorder, or legal services. The ideal is for the patient to speak with NHTH directly 15 16 17 so that the case can be discussed in detail. If the HCP calls the NHTH, the hotline can provide 18 19 technical assistance including accessing community HT resources. If the HCP contacts the 20 21 22 NHTH and has consent from the patient to share PHI, he/she may discuss the case in detail with 23 24 the NHTH. When calling NHTH without explicit consent from the patient, it is important to 25 26 share only non-PHI, possibly using hypothetical questions  such  as:  “If  I  were  caring  for  a  male   27 28 29 patient from the US who may be labor trafficked, what are local legal services that I can access? 30 31 Are there any shelter options?”  Note, in this example, the HCP mentions the type of trafficking 32 33 34 and gender but does not disclose the date of service. 35 36 37 38 39 Case 3: Need for guidance in caring for a potential victim of HT 40 41 This case raises the HCP’s  index of suspicion for trafficking but she needs further 42 43 guidance on how to explore the possibility of HT with the patient as her facility does not have a 44 45 46 protocol in place. As stated previously, it is essential that a trauma-informed interviewer be 47 48 present, that the patient be interviewed alone without the person who accompanied him/her, and 49 50 51 that a professional interpreter be used when  the  patient’s  first language is not English. The HCP 52 53 may choose to access her facility’s  multidisciplinary resources such as social workers or external 54 55 56 resources such as the National Human Trafficking Hotline (NHTH) to gain guidance on 57 58 questions to ask. The NHTH call specialists are trained to speak with health care providers, and 59 60 61 62 63 64 65 1 11 2 3 Trafficking and HIPAA 4 5 walk them through potential screening questions. (See Case 2 discussion for details about 6 7 engaging NHTH with and without patient consent.) Importantly, the ultimate goal of a clinical 8 9 encounter like this is not disclosure or rescue. If, after further exploration, the patient does not 10 11 12 disclose human trafficking, the HCP should still consider providing safety planning and 13 14 anticipatory guidance to the patient as they may be at high risk for trafficking. As a safety line, 15 16 17 the NHTH number can always be discreetly given to a potential victim, for him/her to call or text 18 19 at a later date (Call: 1-888-373-7888; Text: HELP to BeFree (233733)). In addition, a follow-up 20 21 22 appointment may be made with the patient to return. Overall, it should be clear that the health 23 24 care setting is a safe haven for the potential victim to return. 25 26 27 28 29 Case 4: Disclosing PHI without consent, due to imminent threat to safety 30 31 This case raises the issue of imminent danger. As the patient is fearful himself, he might 32 33 34 consent for LE involvement, so he should be asked. However, in this case, there is also perceived 35 36 imminent danger to the patient and to the staff, and calling LE without the patient's consent is 37 38 39 permitted by HIPAA. It is important to understand that trafficking survivors may have prior 40 41 warrants or charges related to their trafficking exploitation, and so involving LE must be done 42 43 carefully with LE who have HT training. A minimal amount of information should be disclosed. 44 45 46 [place Figure 1 here] 47 48 [place Figure 2 here] 49 50 51 Conclusion and Recommendations 52 53 A health care setting that is informed and equipped on the intersections of human 54 55 56 trafficking (HT), HIPAA, and mandatory reporting will be better able to serve suspected HT 57 58 59 60 61 62 63 64 65 1 12 2 3 Trafficking and HIPAA 4 5 victims. The following general recommendations are made in order to guide HCPs in caring for 6 7 trafficked persons: 8 9 ● Foremost, and in conjunction with the consulted authorities, health systems should 10 11 12 consider the development of a HT protocol which incorporates guidance on HIPAA and 13 14 mandatory reporting laws (Baldwin, Barrows, Stoklosa, 2017; Stoklosa, et al., 2016). 15 16 17 (Figure 2); 18 19 ● HCPs may use the NHTH hotline to be guided through a trafficking screening interview 20 21 22 and identify services for trafficked persons, particularly when a protocol is not in place; 23 24 and 25 26 ● HCPs should familiarize  themselves  with  their  state’s  mandated  reporting  laws  applicable   27 28 29 to human trafficking. 30 31 32 33 34 Acknowledgements: The authors would like to give a special thanks for the perspectives 35 36 provided by Rochelle Rollins, Katherine Chon, Jordan Greenbaum, Jeffrey Barrows, Holly 37 38 39 Atkinson, Nicole Moler, Maralee Gutierrez, Mariam Garuba, and Rachel DiSanto. The authors 40 41 would also like  to  thank  the  US  Department  of  State’s  Virtual Student Foreign Service program 42 43 for its support in the recruitment of student interns for participation in this project. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 13 2 3 Trafficking and HIPAA 4 5 References 6 7 8 9 Atkinson, H., Curnin, K., & Hanson, N. (2016). U.S. State Laws Addressing Human Trafficking: 10 11 12 Education of and Mandatory Reporting by Health Care Providers and other Professionals. 13 14 Journal of Human Trafficking, 2(2), 111–138. 15 16 17 Baldwin, S., Barrows, J., Stoklosa, H. (2017). Protocol Toolkit for Developing a Response to 18 19 Victims of Human Trafficking in Health Care Settings. HEAL Trafficking and Hope for 20 21 22 Justice. Retrieved from http://www.HEALtrafficking.org. 23 24 Beck, M. E., Lineer, M. M., Melzer-Lange, M., Simpson, P., Nugent, M., & Rabbitt, A. 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Retrieved 54 55 56 from: http://sharedhope.org/wp-content/uploads/2014/11/State-Law-Survey-2014- 57 58 59 60 61 62 63 64 65 1 15 2 3 Trafficking and HIPAA 4 5 Likelihood-of-CPS-Involvement-Shared-Hope-International.pdf Accessed June 16, 6 7 2015. 8 9 Stoklosa, H., Dawson, M. B., Williams-Oni, F., & Rothman, E. F. (2016). A Review of US 10 11 12 Health Care Institution Protocols for the Identification and Treatment of Victims of 13 14 Human Trafficking. Journal of Human Trafficking, 1-9. 15 16 17 Stoklosa, H., Showalter, E., Melnick, A., & Rothman,  E.  F.  (2016).  Health  Care  Providers’   18 19 Experience with a Protocol for the Identification, Treatment, and Referral of Human- 20 21 22 Trafficking Victims. Journal of Human Trafficking, 1-11. 23 24 The 189th General Court of the Commonwealth of Massachusetts. (n.d.). Reporting of suspected 25 26 abuse or neglect; mandated reporters; collection of physical evidence; penalties; content 27 28 29 of reports; liability; privileged communication, (Laws/Statutes), 51A. 30 31 U.S. Department of Health and Human Services. (n.d.) (a). Summary of the HIPAA privacy 32 33 34 reporting law. Retrieved from 35 36 http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html. 37 38 39 U.S. Department of Health and Human Services. (n.d.) (b). OCR Privacy Brief: Summary of the 40 41 HIPAA Privacy Rule. Retrieved from 42 43 http://www.hhs.gov/sites/default/files/privacysummary.pdf 44 45 46 47 48 U.S. Department of Health and Human Services Office for Civil Rights. (2013a). HIPAA 49 50 51 Administrative Simplification: Regulation Text: 45 CFR Parts 160, 162, and 164: 45 52 53 C.F.R. § 160.103 (Unofficial Version, as amended through March 26, 2013). Retrieved 54 55 56 from http://www.hhs.gov/sites/default/files/hipaa-simplification-201303.pdf 57 58 59 60 61 62 63 64 65 1 16 2 3 Trafficking and HIPAA 4 5 U.S. Department of Health and Human Services Office for Civil Rights. (2013b). HIPAA 6 7 Administrative Simplification: Regulation Text: 45 CFR Parts 160, 162, and 164: 45 CFR 8 9 164.512(j) Uses and disclosures to avert a serious threat to health or safety. (Unofficial 10 11 12 Version, as amended through March 26, 2013). Retrieved from 13 14 http://www.hhs.gov/sites/default/files/hipaa-simplification-201303.pdf 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 Figure 1 Click here to download Figure Figure 1 Jan 10-2.docx Figure 1 Following HIPAA and caring for the trafficked patient, using the National Human Trafficking Hotline (NHTH) HCP* identifies a suspected victim of trafficking Needs -assessment, safety-planning Identify local anti-HT† resources If case meets mandated reporting requirements, HCP reports case to authorized entity, disclosing minimum PHI‡, informs patient of disclosure Patient does not consent to share PHI without disclosing PHI, HCP may request information about local social and legal resources from NHTH Patient consents to share PHI HCP requests information about local social and legal resources from NHTH Patient speaks directly to NHTH to request resources *HCP=health care professionals †HT= human trafficking ‡PHI=  protected health information If there is imminent danger to a patient or public, authorities may be contacted without patient consent, disclosing minimum PHI Figure 2 Click here to download Figure Figure 2 Jan 10-2.docx Figure 2 Considerations for health care institutions in designing a human trafficking (HT) protocol Step 1: Design HT protocol for healthcare setting: A)  Meet  with  institution’s  privacy  officer  to  learn  your  institution’s  policy  for   PHI, HIPAA, and relevant reporting procedures and documentation germane to HT victims. B)  Know  your  state’s  mandatory  reporting  requirements.  Familiarize  yourself   with your local HT-trained LE*, CPS†, and the other authorities to whom you may be required to report. C) Understand the services available to potential victims of trafficking in your area, including shelter, medical care, substance use disorder treatment, and mental health services. D) Organize team of multidisciplinary healthcare and community stakeholders E) Meet with administration and stakeholders to create protocol, and harmonize protocol with existing protocols for other forms of interpersonal violence, including child abuse, sexual assault, and domestic violence. Step 2: Train your staff on human trafficking, trauma-informed care, and the protocol; consider simulation cases as part of an interactive training. Step 3: Display posters or public information that will encourage HCP awareness of HT, and presence of HT protocol.‡ Step 4: Evaluate and modify the protocol based on data collected, patient outcomes, stakeholder feedback & changes in laws and policies. * LE=law enforcement †  CPS=  child  protective  services ‡be cautious about posting the information in an area where a potential trafficker may view it