American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Step 5: Building the Support Structure

Establish Standard Processes and Policies to Support Implementation

  • Formalize relationships between the HVIP and community partners through a Memoranda of Understanding (MOU).
  • Train Front-Line Staff: 
    • Training should address recognizing acute stress response and PTSD and an understanding of Trauma Informed Care.
      • Workshops are available through the National Network of Hospital-Based Violence Intervention Programs (NNHVIP).
      • NNHVIP also offers monthly front line staff working group calls to discuss difficult cases and challenges.
  • Ensure accountability: Hold weekly staff meetings with a set agenda, and separate weekly case management sessions to review the number of eligible patients, screening, enrollment, progress, and retention.
  • Connect to community resources: There is data to support mental health, employment, and education as being key risk factors in reduction services. Finding these resources should be a priority early on. Further, peer counselors provide a critical link to mental health services and thus should be incorporated into the mental health care plan.
  • Collect data: Programs should immediately begin collecting data on eligible patients, screening rates by case managers, enrollment rates, early attrition rates, program and patient needs, progress on identified needs, and long-term outcomes.
    • A template to track violence intervention programs was designed by the company QuesGen Systems. Several NNHVIP programs use this template (or an adaptation of it) as a platform in building the multicenter database.

Case Study

A 17-year-old is shot at 10PM on a Friday night. One of the case managers responds to the trauma page. The victim is taken to the operating room and the case manager makes contact with the hospital social worker. Both team members work together to locate and support the family and friends of the victim, and collaborate with other city intervention specialists to reduce chances of retaliation.

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

The case manager visits the victim daily in the hospital, and begins by finding an appropriate place for tattoo removal and a safer school. The client meets with a probation officer at the juvenile justice center, and they work together on program management. The case manager begins to input data daily into the software program, and presents the new client at the case management meeting and staff meeting.

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

Over the course of the next 3 months, the tutoring continues and the case management meetings spread out from daily to weekly. Support for finding mental health services for the mom are also aided by the case manager.

Potential Pitfalls

  • The case manager does not return to the bedside when the client initially says “no” to HVIP services. There are numerous occasions when the first bedside visit is not successful for a variety of reasons. Additional attempts should be encouraged.
  • The case manager does not make contact with the client outside the hospital, even when the client refuses services while hospitalized. Some clients are apt to be receptive to services, even after they have been discharged to their home environment.
  • 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 underway for some individuals. It is also useful for programs to get to know 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 case manager creates a trust bond with the client, it is important to pay close heed to the client’s concerns and fears, or the case manager runs the risk of creating feelings of distrust and abandonment.
  • Clients may feel vulnerable, especially if law enforcement is involved. Their fear of a case manager revealing vital information to law enforcement may cause them to regress.