The idea of using the hospital encounter as a jump-off point to break the cycle of violence is not new.
Some of the earlier programs — like Youth Alive’s “Caught in the Crossfire,” which connects traumatized adolescents with violence intervention specialists at the bedside — date to the early 1990s. But 20 years is still relatively young for a burgeoning offering in the medical field.
One of the early adopters of this concept was Carnell Cooper, M.D., a trauma surgeon and associate professor of surgery at the University of Maryland School of Medicine — the busiest in the nation, treating more than 8,000 trauma patients a year. Cooper was similarly confronted with a crystalizing moment in 1996 when treating an “affable” man in his early 20s. The patient had been shot several times and was dying from his wounds, but surgeons spent the next six to eight weeks performing multiple operations on the man, all while getting to know him.
Less than a year after he was discharged, the man was back with bullet wounds in his chest and head. This time, surgeons could not save him, and Cooper says that death changed his life. “I really felt that there was something else that we could do if we put our minds to it. That kid dying there and, standing at his bedside and hearing folks who said, ‘there’s nothing we could do,’ I just did not believe that was the case,” he says.
From there, Cooper began working with university colleagues to develop a way of helping those harmed by violence to avoid further bloodshed. Digging into the data, they found that 23 percent of those patients were readmitted in the months that follow, and patients who showed up at the trauma center with a second injury were 10 times more likely to die as the result of a subsequent violent injury.
UMMC’s Violence Intervention Program, launched in 1998, involves locating eligible patients through the electronic health record and connecting them with a social worker at the bedside. There, they are assessed and given counseling and any other needed social support, with case workers continuing to work with them following discharge to help avoid further violent incidents.
Nearly 20 years later, Cooper and his colleagues continue to delve into the data to find ways to further refine the program, he says. UMMC was one of the first to do a randomized efficacy study on such intervention programs (which, in 2006, found that those who took part in the program reduced their chances of being arrested for a violent crime compared with those of a control group). He’d like to explore further questions, such as how intervention impacts PTSD and depression, whether it might work with recidivism in the prison population, and if it can be spread across the entire city of Baltimore. Cooper says data will be key to making hospital-based violence intervention programs more mainstream.
“If you’re going to get hospitals to invest money and time and resources into something like this, then you’ve got to have data that show it,” he says.
That’s one of the reasons those charter members formed a national network of programs in 2009 — of which Cooper is a member, and part of the organization’s steering committee — and why they continue to meet. Youth Alive’s Linnea Ashley says that the larger group offers the chance to do more combined studies and analyze larger sample sizes compared with the much smaller blocks of data at the local level. Plus, research around the absence of intervention can be difficult to undertake, and members of the network are still exploring ways to gather more “robust data” on the field.
“This is something that we heartily believe in and it’s not just about anecdotes, but that we are definitely looking for the research to back up what we have seen to be true from our interactions with individuals and with our clients. But we also recognize that that is not enough and we have to find other ways to show that this has been successful.”
Experts say that having further data on the effectiveness of violence intervention could also help with tackling one of the biggest hurdles to this work: funding. Insurers can be reluctant to pay for, and hospital leaders to sign off on, programs that might not be part of the core mission of providing acute care, and that may lack hard and verifiable data to back them up. That’s also why Youth Alive helped to fight for the passage of a bill in California that allows for reimbursement for community violence peer counselors through the California Victims Compensation Program. Elsewhere, states are looking to replicate the legislation, Ashely says.
Adding further to the funding mix, Youth Alive has, along with others in California, created 40 hours of curriculum and training for intervention specialists. This is critical, Ashley says, because interveners are often laypeople without conventional backgrounds who were hired because of their connections to the community and their ability to break down barriers and speak the language of people who are caught up in the cycle of violence. This lends credence to insurers and hospitals who might be skeptical about paying or employing these laypeople. Those in the national network, she says, are now eyeing a national training framework to spread everywhere.
Schwab Rehabilitation Hospital in Chicago is one such provider organization that’s had to grapple with funding cuts, even in the face of soaring violence in the city. The hospital is located on the violence-torn South Side of Chicago, a city that saw more than 760 homicides last year, a 58 percent uptick from that of 2015.
Often, Schwab treats patients who have been shot and are suffering from debilitating injuries. Its patient population is 90 percent Latino and black, and more than 60 percent receive Medicaid benefits. Its intervention programs include “In My Shoes,” a peer-led offering in which former victims of violence show youth what life is like with a traumatic injury; to date, it’s reached more than 52,000 offenders.
And yet, Schwab has had to drop from a dozen or so of those per-led interveners to only a couple at a time when “we need it more than ever,” says Michelle Gittler, M.D., the hospital’s medical director. Schwab has scraped and clawed to find funding while state and foundation dollars have dried up. She believes society must start thinking differently about how to allocate dollars when trying to address violence.
“This is not clinical work, you can’t bill for it, so how do you pay for it?” she says. “I think that we as a society, not just Chicago, have to be willing to recognize violence as a public health issue, and when we look at all of the other things that we do in public health, we need to put that same kind of funding into violence prevention. That means doing research to understand the causal agents, look at the interventions and their efficacy, and make sure that we are targeting the right communities and doing follow-up.”