October 4, 2017
I applied for the American College of Surgeons (ACS) Claude H. Organ, Jr., MD, FACS, Traveling Fellowship with the goal of attaining a better understanding of hospital-based violence intervention programs (HVIPs). As a trauma surgeon, I have always had an interest in public health initiatives related to injury and violence prevention. Having recently moved to Newark, NJ, it was apparent that both the community and Rutgers University would benefit from a HVIP, as urban violence remains a common cause of injury in Newark.1 Specifically, I was interested in learning about the Wraparound Project in place at the University of California, San Francisco (UCSF), and San Francisco General Hospital.
HVIPs have been implemented in several U.S. trauma centers in the last decade, and recently these programs have been emerging nationwide with increasing rapidity.2 According to the National Network of Hospital-Based Violence Intervention Programs (NNHVIP), in the 1990s, only four programs existed nationwide, 10 more were added from 2000 to 2009, and since 2010, 18 programs have launched. In 2009, program directors from across the country formed the NNHVIP to share best practices, to have access to a mentorship program in which new program directors are paired with more established directors, and to help hospitals learn how to initiate HVIPs at their institutions. By learning about HVIPs through the work and publications of the NNHVIP, I was able to develop an understanding of the process needed to start a HVIP in my own institution and subsequently secured a pilot foundation grant from the Healthcare Foundation of New Jersey to support a program in Newark.
Starting a high-quality, sustainable HVIP requires tremendous dedication to the cause, along with a great deal of practical knowledge about how to manage the program. It was with this understanding that I applied for the Claude H. Organ, Jr., MD, FACS, Traveling Fellowship, with the goal of partnering with an established HVIP to gain firsthand knowledge about best practices for managing a HVIP. One of the oldest and most successful HVIPs in the U.S. is the Wraparound Project in San Francisco, which is based at UCSF and San Francisco General Hospital, and managed by Rochelle A. Dicker, MD, FACS, and Catherine Julliard, MD, MPH. The Organ Traveling Fellowship afforded me the opportunity to spend one week at San Francisco General Hospital to learn about the many facets of this program.
My week began with a visit to the hospital to meet the case workers and the injury prevention coordinator, Adaobi Nwabuo, MB, BS, MPH. Case managers are the cornerstone of successful HVIPs. They often meet patients during the “teachable moment” of trauma care when an injured person may be more receptive to services or more prepared to make life changes as a response to their injury experience.3 Case managers meet with and develop a relationship with patients during their hospitalization. They offer immediate services, such as assistance with completing applications for victims of crime compensation, and help with relocation or referrals to mental health services.
After the patient’s hospital discharge, the case worker continues to work with the client to develop goals, find assistance from community-based organizations, apply for job training or other educational programs, or secure employment. The emphasis on long-term commitment to the patient cannot be overstated. Case managers not only refer clients to community-based resources, but also accompany them on visits, assist in completing paperwork, and ensure follow-up. The uptake of community services is much higher using this model than if the patients simply received referrals or a list of available organizations with the expectation that they will follow up independently. It is vital to the success of these programs that case managers be from the communities they serve. Being a member of the community adds to their credibility and will make clients more receptive to the advice offered by their case managers.
Although I had learned about case management processes by reading medical literature on HVIPs, observing the case managers interact with clients allowed me to form a more complete vision of what a HVIP would look like at my own center. I visited the bedside with a case manager to experience how that first, most critical interaction works. I reviewed consents, progress notes, data entries, and documentation to better understand the essential tasks and timeline of case management. The seemingly small tasks of data collection, handoffs, and logistics all weave together to form the complex fabric that makes these programs run efficiently. Seeing the program firsthand allowed me to better understand the intervention and resource needs of these programs. This experience helped me understand what the program might look like on the ground in Newark.
A second key component of HVIPs is the relationship of the program with outside organizations. In a well-developed program like the Wraparound Project, the HVIP has standing relationships with community-based organizations that provide clients with social services. I visited several such programs to see how the clients were progressing at various points in their posthospital discharge, from several months to several years of recovery.
A client from the Wraparound Project stands with his painting. Art is one means of expression and healing after trauma that patients are offered. I had the opportunity to speak to several patients about their journey and healing after traumatic injury.
One program, Friends of the Urban Forest, provides employment through an arborist apprentice program, which trains clients in the skills necessary to care for the city’s trees. Another program, the Trauma Recovery Center, founded by Alicia Boccellari, PhD, provides mental health, counseling, and group therapy services to victims of violence. A third program, Project Rebound, provides guidance, test preparation, and on-campus resources to clients who choose to pursue a college education at San Francisco State University following their injury.
Perhaps one of the more important aspects of the Organ Traveling Fellowship experience was the opportunity to visit all of these partner organizations that interact with patients at different stages of rehabilitation. It was clear that it would be important to develop relationships with Newark organizations that offer job training, employment, and mental health services.
As I was visiting the partner programs and reflecting on my experiences, I began to recognize my own implicit bias. Previously, this bias clouded the way I defined “recovery” for victims of violence. Seeing former trauma patients at various stages of healing changed my perspective regarding what to expect from individuals as they recover from traumatic injury. As surgeons, we see patients for a few postoperative visits, but we may have an incomplete understanding of how long it takes someone to heal from the psychosocial trauma of being a victim of violence and how that affects their recovery. Having a better understanding of how recovery can be experienced differently depending on the individual situation, and how nonlinear that pathway can be, helped inform my expectations for my own program’s success.
Another component to consider when starting a HVIP is how the program will coexist with other citywide violence prevention initiatives. In San Francisco, the mayor’s office holds a weekly victim services response meeting. This meeting brings together various community-based organizations, the Department of Public Health, the Wraparound Project, and individuals representing public housing, public schools, and law enforcement to review the cases of violent injury from that week. In each case, a comprehensive strategy is coordinated that includes law enforcement, victim services, and family services to ensure that all victims are reached and to avoid redundancy. This comprehensive strategy was so impressive that I was compelled to initiate a similar victim services response meeting in Newark. Although Newark cannot reproduce every detail of the San Francisco victims services coordination system, the idea that this kind of collaboration exists was essential to launching the HVIP at my institution.
Finally, as the manager and hospital champion for the initiation of a HVIP, it was imperative that I understand the funding and evaluation mechanisms of these programs. The funding process is circular. Evaluation compels more funding, which, in turn, helps to fund more evaluation.
Dr. Bonne attended a weekly victim services response meeting with the Wraparound staff, held at the iconic San Francisco City Hall. Staff from various violence intervention initiatives citywide meet weekly to coordinate services offered to victims of violence and their families.
I had the opportunity to meet with the members and staff of the San Francisco General Hospital Foundation to discuss funding opportunities and logistics specifically involved in foundation support of a HVIP. I also visited the Law Center to Prevent Gun Violence, a San-Francisco-based not-for-profit organization that has a group of attorneys and grant writers dedicated to uncovering research funding opportunities for HVIPs and advocating for policy initiatives to support public health models of violence prevention, including HVIPs.4
Once funded, whether by the hospital or through private grants, an essential component of the program is evaluation and data collection. In addition to collecting basic demographics, tracking the uptake of services, referrals, and the outcomes of these programs is critical to determining a center’s success. The NNHVIP is poised to start data sharing and the creation of a national database will track outcomes and provide research opportunities. As a junior faculty member, the opportunity to better understand these data points and the research potential of HVIPs solidified my academic interest in these programs.
The data gathered from successful HVIPs show strong interaction with community-based services, notable reduction in costs, and modest decreases in recidivism.5-7 HVIPs operate on a public health secondary prevention model that seeks to limit the burden of disease or, in the case of HVIPs, violence, on an already affected population. Recidivism seems to be the most obvious outcome measure on which to base the success of these programs. However, after spending a week immersed in the Wraparound Project and speaking with case managers, staff, and clients, I learned that prevention outcomes are more complex than simply tracking whether a person is injured again. Uptake of resources, reentry into school or the workforce, positive mental health outcomes, or qualitative outcomes like increased self-esteem, goal-setting behavior, and life outlook are all much more meaningful than recidivism alone.
The portability of HVIPs has been more challenging, as each program, while drawing from the same essential structure, needs to be tailored to the community in which it is implemented.8 Visiting a successful program was essential to my understanding of the functional aspects of the program, but I also learned that it is important to create a program that is a good fit specifically for Newark. A one-size-fits-all program does not exist, as the individuals involved in providing these services need to be keenly aware of the unique needs of the communities they serve and the forces at play in them. This knowledge comes from the time dedicated to assessing the “lay of the land” of the hospital and the city in which the program is intended to start.
In summary, having this firsthand opportunity to see a mature program in action solidified my understanding of the functional aspects I need to set in place to create a successful HVIP in Newark, and the ways in which I can build a successful academic career by implementing and evaluating HVIPs from a public health perspective.
I cannot thank the ACS enough for the tremendous opportunity afforded me by the Claude H. Organ, Jr., MD, FACS, Traveling Fellowship, and I look forward to building a robust program so that I may mentor others in the future, thereby carrying on Dr. Organ’s legacy.