Hospitals tackling gun violence as a public health issue
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Gun violence didn’t stop during the COVID-19 pandemic—in fact, it escalated.
Nearly 20,000 people died from shootings and firearm-related injuries last year, marking the deadliest year for gun violence since the 1990s. That number rises to more than 43,000 people when including 24,000 who died from suicide, according to the Gun Violence Archive, a not-for-profit that tracks shootings.
And 2021 is on the same tragic course. More than 180 people were killed in shootings across the country over the Fourth of July holiday weekend, bringing the total number of gun-related deaths as of July 6 to 22,668. There have been more than 300 mass shootings this year, including highly publicized incidents in Atlanta, Boulder, Colo., and Indianapolis.
The “surge in gun violence” spurred President Joe Biden in June to introduce a new strategy to target gun crime prevention and response—including encouraging local governments to scale up “wraparound services” for crime victims and calling on Congress to allocate billions of dollars toward community-based violence intervention programs that provide such services among other measures related to gun control.
Some hospitals have already taken on that mantle, launching programs that link patients with mental health services, community resources and other follow-up care in the aftermath of a firearm injury, with a goal of reducing future violent injuries by encouraging patients to change behaviors that might lead them down a similar path or to retaliate against the person who injured them.
“We know that people who are violently injured are very much at risk of being injured again,” said Dr. Kyle Fischer, policy director at the Health Alliance for Violence Intervention, a network of hospital-based violence intervention programs—programs that collaborate with community groups to provide patients with wraparound services after a violent injury.
That can include everything from setting patients up with food vouchers, assistance with earning a GED certificate, job training and housing support, to alcohol and substance abuse treatment.
Hospitals are arguably an ideal place to house—or at least initiate—such programs. In trauma care, people talk about the “golden hour” immediately following an injury, when medical treatment is most likely to prevent death; there’s a similar golden opportunity in the aftermath of a violent injury, proponents say, with an opening to talk to patients about how to prevent their next injury.
It’s similar to how a patient may be more amenable to discussing smoking cessation after a heart attack.
In the hospital, case managers can identify patients at risk of sustaining another violent injury—”and then (figure out) how to provide services, resources, whatever they need to address the underlying risk factors for injury in their life,” said Dr. Rebecca Plevin, program director at the Wraparound Project, a violence intervention program at Zuckerberg San Francisco General Hospital.
Such hospital-based programs have shown some successes with reducing future violent injuries and improving mental health symptoms—but many say their longevity has been threatened by funding models that tend to rely on short-term grants, rather than payment systems that establish long-term, sustainable programs.
In Chicago, health systems located on the city’s South and West sides, which historically have high gun violence rates, have made inroads through Healing Hurt People-Chicago, a hospital-based violence intervention program and collaboration between John H. Stroger, Jr. Hospital of Cook County Health, University of Chicago Medicine Comer Children’s Hospital and Drexel University in Philadelphia, which developed the first Healing Hurt People program.
HHP-C, which has staffers housed at Stroger and UChicago Medicine’s Level 1 trauma centers, connects program participants with a social worker to coordinate intensive case management and wraparound services, including referrals to community resources and peer support groups.
When it launched in 2013, HHP-C started by enrolling youths up to age 18 who had experienced a violent injury. But as the program has hired more staff, it’s grown to include patients up to age 30.
HHP-C has about a dozen employees who work with patients. The program is partially housed within Stroger’s trauma department, so it’s “embedded” into services offered to patients as a standard of care, said Andy Wheeler, a clinical social worker in Stroger’s trauma center and inpatient coordinator for HHP-C.
Last year, the program served 923 patients. It’s open to patients who present with a violent injury—wounds from a gunshot, stab or assault—from community violence, which includes acquaintance and stranger violence, but not injuries from intimate-partner violence.
Firearm injuries aren’t driven by just one type of violence, and different programs may be targeted toward just a portion of that population, whether suicides, intimate-partner violence, mass shootings, gang-related shootings, targeted shootings or random stranger violence, to name a few. Some programs might also be open to those close to the person injured or witnesses of violence, who often also need trauma-informed care.
The HHP-C program is funded by a mix of state, local and private philanthropic grants, primarily from the Illinois Criminal Justice Information Authority and impact investor Chicago Beyond.
It goes beyond what some might view as hospital care, since it ties in referrals to programs that tackle social determinants of health.
“Violence is a public health issue,” Wheeler said. “It’s our duty to do the things that we can to treat patients even beyond when they leave (the trauma center).”
Dr. Megan Ranney, associate professor of emergency medicine at Warren Alpert Medical School of Brown University in Providence, R.I., said she was once just one of a handful of physicians and researchers openly calling gun violence a public health problem. “That discussion has become normalized over the last five years or so,” she said.
That includes increased attention in Washington, D.C. The American Medical Association in 2016 declared gun violence a public health crisis and called on Congress to lift the ban on studying it as such. And following the mass shooting in Boulder this April, the Biden administration issued a statement calling gun violence a “public health epidemic.”
And while hospital-based violence intervention programs are picking up steam, they are still only offered by a subset of hospitals.
“If you go to most hospitals across the United States, it’s all about treating the physical wound,” said Ranney, who serves as chief research officer for the American Foundation for Firearm Injury Reduction in Medicine, a not-for-profit that brings together healthcare and public health professionals. “That is changing, though.”
That’s led a few dozen hospitals across the U.S. to stand up programs to provide mental health services and connections to community groups that address social determinants like food and housing insecurity, which they say can make that next incident less likely.
One study in Chicago found 8% of patients who participated in a hospital-based violence intervention program reported a repeat injury in the following six months, compared with 20% of those who hadn’t participated in a program. Another study in Baltimore reported 5% of patients participating in a program were re-hospitalized, compared with 36% of those who weren’t.
That said, hospital-based violence intervention programs aren’t easy to set up.
They require hiring—and paying—staff to regularly engage with patients and cultivate connections with the community for services that some might initially view as beyond traditional hospital care.
The cost of a hospital-based violence intervention program varies depending how busy it is, what types of services patients need and, notably, how many staffers a hospital decides to hire. It costs roughly $350,000 annually to run a hospital-based violence intervention program that serves 90 clients, according to a 2015 study published in the American Journal of Preventive Medicine.
Most of that cost goes to funding personnel, namely the staffers who work with patients and connect them to relevant community services.
Stephanie Harris has worked as a clinical case manager with the Life Outside of Violence program, a hospital-based violence intervention program in St. Louis, since 2018.
She says her favorite part of the program is getting to know new people and building a rapport after a patient comes into the hospital, so she can figure out which organizations and services in St. Louis—the city she grew up in—she can connect them with to help them build their future.
It’s “really not knowing what type of situation that a person’s going to come in (with),” Harris said. “It’s part of the challenge, but it’s also a part of the reward.”
The LOV program brings together four Level 1 trauma centers in St. Louis—Barnes-Jewish Hospital, SSM Health St. Louis University Hospital, St. Louis Children’s Hospital and SSM Health Cardinal Glennon Children’s Hospital—and is housed at the Institute for Public Health at Washington University in St. Louis.
The program is funded through a three-year, $1.6 million grant from the Missouri Foundation for Health.
It’s also part of the St. Louis Area Violence Prevention Commission, a group that brings together various gun violence prevention groups in the city.
Harris is one of a team of case managers who reach out to patients who arrive at a participating hospital with a violent injury to tell them about the program, ideally within 24 or 36 hours of presenting at the hospital. Four of the case managers work out of a hospital that they’re assigned to; another is a “floater” who covers all of the units.
She said it’s important to talk with patients to understand their goals and what motivates them, which informs what will drive potential changes in their lives.
If a patient is struggling because they don’t have a job, a case manager can help them build their communication skills and address anger management, as well as talk through how not changing those behaviors may stand in the way of their employment goals. A case manager can also refer patients to services that help with job opportunities and creating resumes.
It’s “really finding out what types of services they might be looking at,” and explaining how the LOV program can provide that, Harris said. That’s usually more effective than just pitching the program right off the bat and trying to convince a patient to enroll, without first understanding what types of support or services they need.
Other hospital-based violence intervention programs call such workers violence prevention professionals, violence intervention specialists, social workers or patient liaisons. They’ll usually be from the community the hospital and patients are based in, and work with patients over the course of six months to a year, though sometimes longer.
Case managers who enroll patients into the program and continue to work with them for the following months to figure out their needs play a major role in these programs’ success. But most case managers aren’t reimbursed by insurance; their salaries are paid for through grants or other sources of funding.
Regional One Health, which runs the Rx for Change program in Memphis, Tenn., has just two staffers—one full time and one part time. Both staffers, called “liaisons,” have social work backgrounds and work with patients to develop service plans and continue following up with them throughout the program.
Rx for Change—and its staff—are funded by Regional One, but the program is applying for grants, with the hope of being able to hire another liaison.
The program’s budget is nearly $80,000 annually.
Staffing “round-the-clock” is critical for a successful program, said Pam Finnie, manager of the trauma program at Regional One. “Make sure you capture those patients who come in at 2 o’clock in the morning. … These crimes do not take breaks. These incidents do not have a holiday.”
Rx for Change has had 352 clients since April 2019, nearly 40% of whom were gunshot wound patients. The program started using a new tracking program for its data in spring 2019, so that’s what its most up-to-date figures are from, according a health system spokesperson. None of those patients have returned with another violent injury.
Hospital-based violence intervention programs are operated through a mix of different funding streams, including research grants, philanthropy and the hospital itself, as well as funding through the Victims of Crime Act, also known as VOCA—a 1984 federal law that established the Crime Victims Fund, which distributes funding to state and local governments to support programs that help victims of crime.
“It’s a little bit different in every program across the country,” said the Health Alliance for Violence Prevention’s Fischer, who’s also an emergency medicine physician at the University of Maryland School of Medicine, and the programs require substantial investment and resources to set up.
The San Francisco Wraparound Project has a unique funding model.
It’s funded through the annual budgets of the city of San Francisco and the SF Department of Children, Youth and their Families. It also applies for grants to fund expanded programs and try out new projects.
Plevin said she considered the Wraparound Project one of the “luckiest” hospital-based violence intervention programs when it comes to funding.
“Where to find money is very difficult for (violence intervention programs) in general,” Plevin said.
With many programs funded through grants, it can be challenging for hospitals to ensure their longevity. It’s not easy to establish programs based on a three-year grant cycle.
There may be more funding coming down the pike. Biden’s American Jobs Plan, released in the spring, asked Congress to invest $5 billion over eight years to support community-based violence intervention programs. And multiple federal agencies in recent months have said existing funding streams can be used for community-based violence intervention programs; the Treasury Department in May, for example, said that $350 billion allocated to state and local funding from the American Rescue Plan can go toward community-based violence interventions.
Fischer said he hopes to see the American Jobs Plan funding passed, so that there can be a more reliable stream of funds for violence intervention programs.
The alliance previously has advocated for using Medicaid to make funding more predictable for hospital-based violence intervention programs.
Since most survivors of firearm injuries are insured by Medicaid, the group has urged Medicaid to reimburse violence prevention professionals for the time they spend meeting with patients and coordinating their care. States aren’t required to reimburse such services, but some states, including Connecticut and Illinois, have introduced bills to do so.
CMS in an April webinar for Medicaid plans gave a hat tip to such a system, encouraging state programs to cover services from hospital-based violence intervention programs.
“In order to predictably and sustainably provide high-quality services for victims of gun violence, these services need to be embedded into the health system,” Fischer said. “Let’s imagine a hospital funded its cardiac cath lab on a three-year grant cycle and were always wondering if they would have the funding to keep the cath lab open to treat heart attacks every three years. … We would be outraged.”
Figuring out future funding is a challenge the LOV program in St. Louis is facing this year, as it approaches the end of the three-year grant period.
The program has seen good outcomes, with less than 3% of participants returning with another violent injury, surpassing the goal of 10%, said Vicki Moran, research coordinator for the trauma department at SSM Health St. Louis University Hospital. She said the LOV program is in the evaluation phase of a new grant it has applied for, but CEOs from the participating hospitals have said they’ll consider funding some of the program, should it run into funding challenges.
“That’s really instrumental,” Moran said. “We now have hospital buy-in.”