Violence intervention programs: A primer for developing a comprehensive program for trauma centers

Injuries resulting from interpersonal violence in the U.S. are all too common. In 2015, homicide was the sixth leading cause of death for all age groups. It was the third leading cause of death in 15- to 34-year-olds, and fourth in children 10 to 14 years of age. Interpersonal violence disproportionately affects minority populations, and homicide is the leading cause of death in young (15 to 24 years old) African Americans and second among young Hispanics. Nearly 1.5 million nonfatal injuries occur among 15- to 34-year-olds, and the direct and indirect cost of these injuries is approximately $12 billion.

Trauma centers stand on the front lines of this interpersonal violence epidemic. With injury recidivism rates as high as 55 percent, injury prevention advocates are exploring ways to close this revolving door to decrease violent injury, using similar methods to those that have been used effectively to reduce the incidence of cardiovascular disease and cancer. Approaching interpersonal violence prevention as a public health issue would allow practitioners to identify risk and protective factors to prevent recurrent injury.

To begin a program to reduce risk factors associated with violent injury, a comprehensive approach that addresses mental health and social determinants of health is critical. Hospital-based violence intervention programs (HVIPs) are multidisciplinary programs that identify patients at risk of repeat violent injury and link them with hospital- and community-based resources aimed at addressing underlying risk factors for violence. Data indicate that HVIPs can reduce violent injury recidivism and hospital costs.

A group from the American College of Surgeons Committee on Trauma (ACS COT) Injury Prevention and Control Committee was tasked with outlining a comprehensive approach to institute a sustainable HVIP. The following is a summary of the concepts outlined in the “Violence Intervention Programs: A Primer for Developing a Comprehensive Program within Trauma Centers” developed by this group in August 2017 to guide fledgling programs and perhaps save new programs from the pitfalls that often accompany this difficult work (see Figure 1).

Figure 1. Timeline for development of a HVIP

Figure 1. Timeline for development of a HVIP

The complete primer is available on the ACS COT website.

Goal

To provide a comprehensive approach to treating victims of interpersonal violence through the development of a HVIP to address risk factors associated with violent injury, thereby providing more complete trauma care, and ultimately reducing recidivism.

Principles

  1. A public health approach to violence prevention
    • Modifiable risk factors associated with violent injury
      • Poor education
      • Lack of job opportunities
      • Injury and criminal recidivism
      • Socioeconomically deprived neighborhoods
      • Substance abuse
      • Complex post-traumatic stress disorder (PTSD)
      • Lack of positive role models
    • Notion of violence as a public health issue with modifiable risk factors first acknowledged by U.S. Surgeon General C. Everett Koop, MD, FACS, in the 1980s
  2. Methodology
    • HVIPs use the “teachable moment,” approaching hospitalized target population patients with culturally competent case managers (CMs).
    • Mental health resources are linked and offered as a core component of HVIPs.
    • CMs develop rapport with clients and begin identifying/addressing individual needs with long-term commitment.
    • CMs shepherd clients through risk-reduction resources via strong community/city ties and knowledge of landscape, such as access to job training, education, substance abuse treatment, domestic violence agencies, and so on.

Following is a step-by-step guide to establishing a working HVIP. It describes minimum requirements to run a program and examples of resources that a more advanced program might use.

Step 1: Define the problem

  1. Globally and in your community: Who is your target population?
    • Individuals
    • Families
    • Both individuals and families
  2. Burden of disease
    • Homicide: Number one and number two killer of young African Americans and Latinos, respectively
  3. Understand target population
    • Look up national and local data
      • Sources of national data: the Centers for Disease Control and Prevention’s (CDC’s) Web-based Injury Statistics Query and Reporting System and National Violent Death Reporting System
      • Sources of local data: trauma registry, vital statistics, police data, and child death reviews; examples of data available through these sources include demographics—age, race, location (zip code or census tract)—and geocoding
  4. Determine which programs are present in your hospital and community. Partnering with these organizations leads to program legitimacy and to an understanding of available risk-reduction resources.
    • Emergency medicine
    • Not-for-profit violence prevention programs, such as Cure Violence
    • Juvenile/criminal justice system: police, attorney general’s office, prosecutor
    • Schools
    • City/county health departments
    • Office for Victims of Crime
    • Mayor’s office of community engagement or equivalent
    • Neighborhood efforts of city supervisors
    • Community-based organization (CBO) case management and risk-reduction resources
    • Universities, specifically schools of public health, nursing, sociology, and social work
  5. New/developing program
    • Conduct initial surveillance and needs assessment of community violence; communicate findings to hospital leadership and city officials to build interest among stakeholders
    • Develop social capital through attendance at CBO meetings to build alliances and commitment to serve the community
    • Engage community leaders to help create a HVIP
      • Obtain input from community on building the case management team
    • Impress upon hospital leadership and CBOs that the status quo is unacceptable. Violence should never be “normalized” in any community
  6. Established program
    • Understand dynamic process: Local target population and efforts inside/outside the hospital
    • Periodically circle back to ascertain the population most at risk; priorities, funding, and capacity changes in cities/CBOs
    • Constantly reevaluating provider landscape aids in building networks and strengthening regional/citywide efforts
  7. Potential pitfalls
    • Lack of comprehensive surveillance
      • Reference multiple data sources, such as trauma registries and police data, when conducting surveillance to understand target population
    • Avoid replicating services and working in isolation
      • Understand the violence prevention landscape in community to avoid replicating services and look for opportunities to potentially merge efforts
      • Team approach is more effective; “it takes a village”
      • Interact with communities at-risk to develop trust and buy-in

Step 2: Building the foundations: Finding champions and collaborators

  1. Understand your institution/university, and opportunities for students and residents to be involved
  2. Change the administration’s perception of the hospital’s role
    • Establishing a program geared toward vulnerable populations boosts hospital optics
    • Public relations: Roll out program
    • Media event involving mayor, hospital chief executive officer, city supervisors, and so on
    • Collaborate with social services department
    • Public safety/security: Understand concerns and how a public figure could help temper emotions in the community after an event
    • Hospital staff are part of the community
      • Educate hospital staff; reinforce importance of this public health issue that can be addressed in your setting
      • Victims of Crime Act (VOCA) accountability at your institution
    • Is VOCA present and efficient?
    • Identify key community stakeholders
  3. Use local CBOs (break barriers): At-risk communities should be part of development and implementation of program
    • Attend meetings
    • Identify community leaders and CBOs that offer resources for risk reduction
      • Have community choose CMs
        • Community partners (CPs) will differ depending on target population/resources.
        • Initially, CBOs may supply CM services when you are unable to support CMs.
      • Introduce HVIP concept at staff, leadership committee, and CBO meetings
        • Individualization is key.
        • Stakeholders want to understand potential human value, but also may be interested in financial impact.
        • A CBO may want assurance regarding the role that the community will play in program.
    • Designate an inhospital champion (trauma surgeon or emergency physician)
    • Key for advocacy
    • Should encourage an open-door policy to ensure critical issues are promptly addressed
    • A community partner is important for developing partnerships when ready to secure with risk-reduction resources (Step 3)
  4. Potential pitfalls
    • Personnel who assume violence is not “modifiable” require patience
    • Culture inside and outside of hospital
      • Repeatedly remind people that violence is never acceptable or normal
      • Acknowledge that risk factors are modifiable
    • Lack of stakeholder buy-in; occurs for a number of reasons
      • Messaging to particular groups is out of line with priorities of a particular stakeholder
      • Stakeholders feel overlooked in development and implementation
      • Failure to address priority items of particular stakeholders

Step 3: Developing the essential resources

  1. Culturally sensitive/competent CM: Key component of a successful program
    • Longer-term CM model (beyond hospitalization) with participant follow-up and tracking
    • Unique qualities of CM position
      • Often have experience with violent neighborhoods
      • CM must have ability to:
        • Accurately screen for high-risk individuals
        • Conduct needs assessment with clients
        • Develop almost instant rapport
        • Shepherd clients through risk-reduction resources
        • Follow up for more than three months post-injury
  2. Identify your “hospital champion”
    • Usually a clinician from the trauma or emergency medicine services who meets the following criteria:
      • Is committed to advocacy
      • Plays large role in development, implementation, and program sustainability
      • Increases exposure of program
        • Research
        • Fundraising
        • Grant writing
      • Usually is affiliated with other HVIPs and injury prevention efforts locally/nationally
  3. Potential pitfalls
    • Lack of dependability on partner organizations for risk reduction
      • CBOs may have insufficient slots for services they provide
      • Important to establish memoranda of understanding (MOU), enabling transparency of expectations
    • Leaving out vital component of hospital or community
      • Can lead to feelings of exclusivity and poor future communication
      • Truly “takes a village” and is very emotionally charged at times
    • Population struggles
      • Individual may not stay with job or school/general education diploma program, initially—important to recognize as long-term goal
      • Criminal records may hinder employment opportunities; job readiness/vocational training partnerships are key

Step 4: Implementation: Developing the programmatic structure

  1. Building the team: program administration
    • Program executive director: typically a trauma surgeon or emergency physician
    • Program manager: typically an injury prevention coordinator in new programs; this position is not essential if director has time
  2. Building the team: frontline staff/case managers/intervention specialists
    • Great candidates often found working in CM capacity at CBO
    • Consider panel interviews, involving people from community
    • As program grows, useful to have supervising CM
    • Important to have at least two CMs to start—a lone soldier has a difficult job
    • New programs often have MOUs with CBOs for CM services, which allows time to secure funding, demonstrate value, and build bridges to community
  3. Training frontline staff
    • Should address recognizing acute stress response, PTSD, and understanding of trauma informed care (TIC)
    • Workshops are available through the National Network of Hospital-based Violence Intervention Programs (NNHVIP)
      • NNHVIP offers monthly working group calls to discuss difficult cases and challenges
  4. Accountability
    • Weekly staff meetings with set agenda, and separate weekly CM sessions to discuss number of eligible patients, screening, enrollment, progress, and retention
  5. Data collection
    • Immediately begin collecting data on eligible patients, CM screening rates, enrollment rates, early attrition rates, needs assessment, progress on identified needs, and long-term outcomes
    • A template to track HVIPs was designed by QuesGen Systems, which several NNHVIP programs use or adapt as a platform in building a multicenter database

Step 5: Building the support structure

  1. Referral to mental health system
    • Mental health services are an essential component of the program
    • Best practice is to have an integrated model where CM and mental health services begin simultaneously and work together throughout client’s tenure
    • Clear referral pattern for mental health is important, if these services are not integrated
    • Strong links between CMs and mental health providers needed; tight partnership between CM services of HVIP and mental health providers is essential in enrolling and sustaining participation of clients in mental health services
      • Mental health peer counselors provide critical links to mental health services
      • Examples of mental health approach: TIC, acknowledgement of longstanding traumatization, moral reconation therapy, trauma-focused cognitive behavioral therapy
  2. Referrals for housing, employment, school, and other services (based on community)
    • Prioritization of mental health, education, and jobs as core resources for clients of programs
  3. Multidisciplinary integrated approach
    • Involvement of other disciplines, including pediatrics, psychiatry, and family medicine, along with medical students, is helpful in finding resources, building bridges, and educating
    • Involving people with expertise in both qualitative/quantitative analysis and health economists can strengthen ability of program to conduct research and evaluation

Case study: A 17-year-old male shot on a Friday night. One of the CMs is working and responds to trauma page. Victim is taken to operating room, CM contacts hospital social worker. Both individuals find family and friends of victim and work to support family and work with other city intervention specialists to reduce chances of retaliation.

Two days later, victim is in position to talk with CM, as he is recovering from bowel injuries. CM uses “teachable moment” at the bedside to expose victim to premise of program and assess victim’s risk of reinjury. The CM deems individual high-risk and offers program’s services. Victim and his parents sign consent forms so that data can be stored, and a needs assessment is performed.

CM visits victim daily in hospital and finds a place for tattoo removal postdischarge. He meets with probation officer at juvenile justice, and they work together on program management. He also inputs data into software program and presents new client at CM and staff meetings.

Once the client is discharged, focus is on working with school counselors, parents, and the district to move client to a safer school. When ready, the client enrolls in a new school and receives tutoring from the volunteers at the HVIP.

Over course of next three months, check-in spreads out from daily to weekly, and tutoring continues. CM also assists victim’s mother in locating mental health services.

  1. Case study pitfalls
    • CM does not return to bedside when client initially refuses services. Often, first bedside visits are unsuccessful. Try again.
    • The CM loses contact with client outside hospital, even when client refuses services while hospitalized. Some clients are apt to be receptive to services, even after discharge.
    • Not exploring potential partners on the criminal justice side could undermine the management plan. It is important to recognize that court-mandated activities may be under way for some individuals. It is also useful for programs to establish relationships with judges in order to best advocate for their clients.
    • Lack of engagement with families (particularly when victims are youth) may hurt the chances of enrolling potential clients.
    • Once the CM creates a bond with the client, it is important to pay close heed to the client’s concerns and fears, or run the risk of creating feelings of distrust and abandonment.
    • Clients may feel vulnerable, especially if law enforcement is involved. Their fear of a CM revealing vital information to law enforcement may cause them to regress. HVIPs can obtain certificates of confidentiality from the National Institutes of Health (NIH).

Step 6: Evaluation—Based on CDC’s recommended broad outline of how to evaluate a community-based injury prevention program with the public health model in mind

  1. Evaluation starts day one
    • Most critical to evaluation process: There is more to evaluation than just capturing recidivism
      • Intermediate and surrogate measures (for example, finding employment)
      • Qualitative outcomes
    • Evaluation standards
      • Reach (for example, are CMs conducting bedside interventions before discharge?)
      • Feasibility (for example, is the target population being enrolled and staying enrolled?)
      • Functionality
    • CM evaluation
      • Are CMs “connecting” with the target population?
      • Are CMs conducting a needs assessment?
      • Are CMs finding appropriate risk-reduction resources in the community?
    • Process outcomes: Are clients sticking with resources? If not, why not?
      • School
      • Employment
      • Mental health follow-up
      • Staying connected to their CMs
    • Long-term outcomes
      • Injury and criminal recidivism
      • Qualitative value of program
        • Qualitative analysis—critical in understanding the inherent value of the programs not captured in the typical quantitative measures
          • Semi-structured interviews and evaluation for common themes can reveal value not captured by other measures
      • Cost-effectiveness analysis
  2. Potential pitfalls
    • Evaluation as an afterthought will lead to lack of evidence
    • Poor enrollment of target population occurs if programs do not reassess registry data to expose at-risk groups
    • Programs need to adapt to address unforeseen population/resource changes
    • Singular evaluation of outcomes, such as recidivism, misses nuanced value of programs

Case study: Robert joined a violence prevention program after being hospitalized for his second violent injury. When he recovered from his injury, his CM, who had assessed his needs, accompanied him to mental health services for three months. Robert’s anxiety was improving, and he felt ready to work. The CM was able to help place him in a program in which Robert would learn how to be an arborist. This program paid a stipend and had the potential of landing him a permanent job. Robert stuck with the program and felt empowered by the skills he was learning. He was put in charge of teaching middle-schoolers how to trim trees during a summer seminar. Six months after the program initiation, Robert was on his home front steps arriving from work when he was shot in the leg. Robert was treated for his injury and recovered enough to go back to the arborist program several months later.

This story brings to light the painful fact that secure housing may not be safe housing. Is this recidivist event considered a failure of his violence prevention program? Not necessarily. While we may be unable to modify all risk factors in a client’s life, such as the surrounding community, the services provided to a client, such as mental health services and vocational training, should be taken into consideration when evaluating the outcomes of these public health programs. If only recidivism is tracked, the other components of value will go unrecognized.


Step 7: Budget and sustainable funding

  1. Bare-bones program budget
    • In-kind support for the director and prevention coordinator
    • Two full-time CMs at $35,000–$60,000 plus benefits
    • Software program at $6,000–$12,000
  2. Established programs increase budgets for more CMs, and pay percentage of salaries for administrative staff, program evaluators
  3. Funding sources
    • Hospital and private foundations
    • City government (line items in city budgets)
    • Federal
      • Department of Justice
      • Department of Defense
      • NIH
      • CDC
      • Victims of Crime Act fund
  4. Potential fee-for-service billing
    • There is taxonomy for CMs; frontline staff acknowledged as part of health care team

Step 8: Advocacy

  1. Contact hospital or university foundation for advocacy, financial support

Case study: Bank of America Foundation approached one hospital foundation. Bank of America was interested in supporting the underserved community in improving the economic state. In conjunction with the foundation, the HVIP worked with an urban arborist program to create a vocational training program for clients with the potential to secure a city or private arborist job at the end of the internship.

  1. Fee-for-service billing
    • State-level bills advocating for CMs to be capable of billing Medicare for their services are under review, with an ultimate goal of federal-level policy
    • May be able to advocate at the state level for this form of reimbursement
  2. Potential pitfalls
    • Missed opportunities to highlight the program in press conferences and in city hall; poor social media presence and lack of public advocacy leads to missed opportunities for buy-in, financial support, and political backing

Note

For more information about the violence intervention programs primer, contact Tamara Kozyckyj, Coordinator, Trauma Systems Programs, tkozyckyj@facs.org.

The authors are all members of the ACS COT Injury Prevention and Control Committee’s Violence Prevention Programs Workgroup.


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