102 - Supporting Implementation of Universal IPV Education in Pediatric Primary Care: A Mixed-Methods Quality Improvement Study of the CUES Model

Publication Number: 2097.102

Alexandra J. Lewis, Yale School of Medicine, Boston, MA, United States; Sundes Kazmir, Yale School of Medicine, New Haven, CT, United States; Brianna Oakley, Yale University, Orange, CT, United States; Samantha Garbers, Northeastern University Bouve College of Health Sciences, Boston, MA, United States; Gunjan Tiyyagura, Yale School of Medicine, Cheshire, CT, United States

Background: Intimate partner violence (IPV) is a common adverse childhood experience, with 1 in 4 children exposed during their lifetime. Pediatricians are well-positioned to support families, yet traditional screening misses many opportunities for intervention. The Confidentiality, Universal Education, Empowerment, and Support (CUES) model, recommended by the American Academy of Pediatrics, provides an evidence-based approach to universal IPV education independent of disclosure. This mixed-methods quality improvement (QI) study is the first to implement and evaluate CUES in pediatric primary care.

Objective: To 1) increase delivery of CUES from 0 to 50% of well-child visits (ages 0-5 years) in a federally qualified community health center and 2) identify barriers and facilitators to implementation using the Consolidated Framework for Implementation Research (CFIR 2.0).

Design/Methods: From June 2024-January 2025, multidisciplinary stakeholders (medical providers, nurses, and IPV advocates) identified key drivers of CUES delivery through surveys and recurring meetings (Fig. 1). Iterative Plan, Do, Study, Act cycles informed intervention refinement, including provider training, integrating CUES into established workflows, and adding electronic health record prompts. Formal implementation began February 2025. We tracked weekly CUES uptake using statistical control p-charts (Fig. 2). To explore barriers to implementation, we conducted 11 semi-structured interviews with clinicians and coded transcripts with CFIR constructs to identify contextual factors influencing adoption (Fig. 3).

Results: From February-September 2025, 3,747 eligible visits occurred, with 1,561 CUES cards distributed (42%), a sustained increase from 0% pre-intervention, suggesting evidence of special cause variation and a shift toward improved performance (Fig. 2). Despite achieving practice change, overall uptake plateaued around 40%. Qualitative findings highlighted barriers, including workflow constraints, language/cultural accessibility, and provider discomfort, and facilitators such as leadership support, individual motivation, and alignment between CUES and the clinic's mission. Themes were mapped to CFIR domains (Fig. 3).

Conclusion(s): Implementing CUES using a structured QI framework produced meaningful practice change in pediatric primary care, with 42% of families receiving IPV education. Qualitative analyses revealed key contextual drivers explaining variation and will inform next steps to enhance CUES uptake. Combining QI methodology with implementation science may guide effective, equitable, and scalable trauma-informed care initiatives.

Figure 1. Key Driver Diagram
This key driver diagram outlines the quality improvement framework used to integrate CUES (Confidentiality, Universal Education, Empowerment, and Support)-into a pediatric primary care setting.

Figure 2. Control Chart
Weekly p-chart displaying the frequency of eligible well-child visits during which CUES cards were delivered from February-September 2025.

Figure 3. Barriers and Facilitators to CUES Implementation through CFIR Constructs
Key barriers and facilitators to implementing CUES in pediatric primary care, mapped to CFIR 2.0 domains.