As COVID-19 pandemic-related concerns begin to recede, long-standing health issues that were overshadowed during the crisis have re-emerged — in particular, the number of patients presenting to medical facilities with violence-related injuries.
A new report indicates nearly 1.5 million people age 2 to 17 years seek medical care each year as a result of some form of violence, a figure 4.5 times higher than prior estimates that included only ED data.1 Further, research suggests that up to 40% of all patients who present to the ED with violence-related injuries return to the ED with a repeat violence-related injury within five years.2
In response, there are calls for hospitals and EDs to take steps to break this cycle by bringing appropriate resources to bear when any patient presents with a violence-related injury. Naturally, emergency medicine practitioners are taking the lead on many of these efforts. Experts in this arena note that even with many competing priorities in healthcare, funding and support for this work is much easier to come by these days than it has been in years past.
One of the newest such programs is Project HEAL (Help, Empower, and Lead) at Hackensack Meridian Jersey Shore University Medical Center in Neptune, NJ. Aakash Shah, MD, the program’s medical director and an emergency medicine physician at the hospital, says a driving motivation for the program was the growing recognition that violence tends to be cyclical.
“I have lost count of the number of times that I have had conversations with patients who are victims of violence, whether that is domestic violence or gang violence,” he explains. “One of the things that has always struck me is that all too often I find myself having these conversations with [the same victims] more than once.”
Consequently, a primary goal of Project HEAL, which works in coordination with the hospital’s department of psychiatry and behavioral health, is to break that cycle by recognizing and intervening with patients when they first present to the ED with a violence-related injury. Shah emphasizes such patients will receive the same prompt medical care for their injuries that they have always received — with an added element to their care.
A tech, a nurse, or the treating physician will notify the charge nurse that a patient with a violence-related injury is in the ED. The charge nurse will contact Project HEAL to send over a violence intervention specialist to meet with the patient while he or she is in the ED.
Typically, at Project HEAL, violence intervention specialists are peers who come from the same communities as the patients. Many of these peers have experienced violence-related injuries. They become hospital employees, undergoing several weeks of training for the role.
The offices of Project HEAL are close to the hospital. When a charge nurse calls about a consult, it does not take long for the specialist to connect with the patient at the bedside. Once there, the specialist will obtain the patient’s permission to work closely with hospital case managers and social workers to develop an individualized service plan and coordinate wraparound services that will continue beyond the point of discharge.
Shah says he and colleagues have moved away from the “treat and release” approach. “Instead, we are continuing to work with [violence victims] for weeks, if not months,” he says.
For example, if case managers and social workers realize the patient needs not just care for wounds but also educational opportunities, Project HEAL partners with the local community college to meet those needs. Similarly, there are resources for training and placement, housing, mental health, and treatment for substance use disorder. The latter is a condition that applies to about half of all of Project HEAL patients, according to Shah.
To optimally meet the needs of patients who have been injured by violence, it helps to develop strong connections with the community. For instance, Shah recalls the case of a patient who was shot in a gang-related incident.
“A fellow gang member came up to us and said that he appreciated all that we were doing for [the patient] in the hospital, but he said that the minute [the patient] touched the street, he would be shot again,” Shah says.
The gang member indicated what the patient really needed was a one-way bus ticket to North Carolina where he could stay with his grandmother and be safe. “In the absence of us providing the patient a one-way bus ticket to North Carolina, all that would have happened, based on the estimation of [the patient’s] own peer, is that he would have wound up, best case scenario, back in the ED,” Shah observes.
Before Project HEAL began connecting with patients in the ED in March 2021, there was plenty of prep work. For instance, program supervisors spent weeks going to every ED huddle to ensure each staff member was aware of the program, what it does, and how to contact the organization. “It is a process of continual reinforcement. We join for department meetings to discuss which patients we should be called about, and to provide examples of patients that staff members have already called us about and what the outcomes were,” Shah says. “This is so everyone gets a more granular sense of what we are doing and how, so that [the program] is always in the front of their minds in case they see someone who might benefit.”
One of the challenges program developers have encountered is many people assume Project HEAL only works with victims of domestic violence. The reality is the program works with victims of all types of violence. “I would argue that our work with [the victims of gang violence] is just as important,” Shah says. “Today’s victims can be tomorrow’s perpetrators.”
Project HEAL is only months old, but Shah is hoping to drive home this message regarding the wide scope of the program, not only to ED staff but also to community neighbors. In fact, Shah still takes a handful of shifts in the ED every week, which allows him to nurture existing relationships there. “This program is designed in a way so that it really does minimize the lift for the ED team ... so that they are not doing anything extra,” he says. “When I am on shift in the ED, I appreciate that ability to know that I can put out a call and solve some of those toughest and most important issues facing my patient, issues that until now the ED was not designed to resolve.”
Established in 2012, The Violence Intervention Program (VIP) at Children’s Hospital of Philadelphia (CHOP) shares many of the same goals as Project HEAL. Joel Fein, MD, MPH, the emergency physician who founded the program, continues to direct the VIP while also serving as co-director of CHOP’s Center for Violence Prevention.
Usually, a social worker in the ED will spot young people who present with violence-related injuries, but other clinical staff members can refer these patients to the VIP. “If the patient is admitted or is in the ED for a long enough time, one of our violence prevention specialists, [all of whom are] hired through the hospital, can see the patient [at the time of presentation],” Fein explains. “Oftentimes, the patient is sent home before the violence prevention specialist can get to the ED. [In that case], we make sure that we connect with the patient in the next few days.”
There are several mechanisms in place to ensure patients with violence-related injuries who present to the ED are identified and contacted by the VIP. Fein notes the VIP has asked its fellows and the nurse practitioners who work in the ED to be aware of any patient who is violently injured and to refer each to the program. “Even if the patients don’t have any interest in our program, they may need help reporting to the police or even just navigating the healthcare system after their ED visit,” Fein says.
Further, there are research assistants associated with the VIP who are in the ED often for many hours a day. They can refer patients to the program, along with providing some initial information. “We also track every violently injured patient who comes to the ED through an electronic medical record [EMR] review,” Fein says. “Within a week of that patient being in the ED, having not been referred, we will still call them and try to recruit them into the program ... we have a backup system for recruiting patients that way, and quite a number of patients are recruited through EMR surveillance.”
VIP is voluntary, but if the patient and family agree to participate, the first step is to conduct an assessment. “We try and go to the patient’s home; obviously, over the last year, this has been done virtually,” Fein reports. “That assessment establishes mutual goals for the patient and the family ... we also think about what the family may need to both recover and heal from the event, and also what they may need in general for this [violent injury] to not happen again.”
Currently, all violence prevention specialists at CHOP hold a master’s degree in social work. They are highly trained in setting up wraparound care to meet the goals established during the assessment. For instance, the family may need assistance setting up an individualized education program (IEP) at the patient’s school while the youth recovers from his or her injury.
“The family may also need special circumstances or a safety plan, which is the most important thing we do, both in the community and in the school,” Fein notes. This requires an assessment of the potential for future violence, such as the possibility of retaliation.
Some families may need help with court proceedings or reporting to the police. Many people need help finding new housing because it is dangerous for them to stay in their current homes. Fein says all the social determinants of health, including food, water, and shelter, are considered.
Patients engaged in the VIP often require mental healthcare. They may be suffering from PTSD following the violent incident that caused their injury. Fein notes these patients also might present with other mental health needs that led to the injury or were concurrent with the reasons staff saw the patient in the ED. “We can connect them with mental healthcare providers, but we can also connect them with certain therapies through our program,” Fein explains.
For example, some older kids in the program participate in a trauma-informed therapy group called Building Resilience After a Violent Event (BRAVE). “We have been holding these sessions virtually [in recent months], but we [generally] hold them in person every month,” Fein says. “This is a 10-session program that patients go through to help them identify their own trauma, understand what is called the self-awareness around trauma, and then heal as a group from their injuries.”
How do program leaders know their approach is working? Fein explains they determine if the mutual goals that have been established as part of each patient’s individualized plan have been achieved. “For example, probably 75% of our patients have mental health goals, and we have been able to meet 80% of those needs,” he says. “We meet almost 100% of the safety and danger goals because that is the most important thing we can do for the family.”
It is harder to gauge how patients who engage with the VIP fare in terms of avoiding violent injuries well into the future. “For each kid, that is the goal — for them not to be reinjured,” Fein says.
However, because many of these patients are adolescents, it is challenging to obtain a statistical read on how they perform once they leave the pediatric healthcare system.
The VIP’s multitude of resources may seem unrealistic to other facilities with similar needs, but Fein stresses the program began with one part-time person, and then gradually expanded from there. Further, he notes there is growing advocacy and support for such programs. For instance, Fein serves on the advisory board for the Health Alliance for Violence Intervention (HAVI), a national network of programs that serves as a go-to resource for hospitals interested in building or improving their own violence intervention efforts.3
“We started [HAVI] with eight programs in the country, and now there are 42 members with 40 more that are trying to become members,” Fein reports. “This is a burgeoning area of intervention. As we get more and more programs, we are getting more and more evidence.”
The HAVI offers training and technical assistance to new violence intervention programs. It is a source of expertise on many issues ranging from how to work with traumatized individuals to community engagement and safety planning. Fein’s advice to administrators interested in establishing a violence intervention program is to scope out what internal and external resources are in place that could be leveraged. “Every program exists in a different location. See if there are community programs that you can utilize to do some of the work by forming agreements with them,” Fein says.
While hospital-based violence intervention programs can differ in many respects based on community characteristics and available resources, there are some components that are non-negotiable.
“There has to be some trauma-informed training or at least the hiring of trauma-informed personnel,” Fein stresses.
Secondly, such programs need to extend well beyond the ED encounter or hospital stay. “The hospital visit is an important time to connect ... but you can’t just be making a referral from the hospital and then saying goodbye to the patient,” Fein says. “The kernel of the program is working with patients and maybe their families. They become clients because they are no longer patients, but they are people who are in the community with you.”
Finally, Fein advises new programs start collecting data on their efforts immediately. “The way you get more funding is to provide the data to show that there is a need and that you are doing good things,” he says. “If you don’t start that from the beginning, and you forget about the expense and need for collecting your evaluation data, then you are going to have more challenges getting increased funding.”
In fact, Shah argues the need for information-gathering begins even before there is a program.
“I think those who feel passionately about this, those who have an intuitive sense that something about the traditional approach to cycles of violence in the ED needs to change, I would encourage them to start keeping track of the data,” he says.
For example, Shah suggests tallying the number of patients who present to the ED with injuries from assaults, gun violence, and stab wounds. Note where these patients come from and how often they return over several years. Use these data to make the case for change to hospital leaders, perhaps in a memo to the chief medical officer.
Perhaps there are 200 victims of gun and knife violence each year, 30% of whom return to the ED with repeat violent injuries. The vast majority of these are uninsured or underinsured.
“Is there an opportunity here to intervene on these cycles of violence in a way that not just makes clinical sense but also makes economic sense?” Shah asks. “I think leveraging that insight can go a long way, even for those who might not have a ready-made funding opportunity before them.”
REFERENCES
- Finkelhor D, Turner H, LaSelva D. Medical treatment following violence exposure in a national sample of children and youth. JAMA Netw Open 2021;4:e219250.
- Turcotte Benedict F, Amanullah S, Linakis JG, Ranney M. Emergency department utilization among assault injured youth: Implication for youth violence screening. Pediatr Emerg Care 2017;33:607-612.
- The Health Alliance for Violence Intervention. What is a hospital-based violence intervention program? https://bit.ly/3j9XDLc
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