Hospital-Based Violence Intervention Programs (HVIPs) aim to reduce retaliation and recidivism among patients being treated for violent injuries by providing in-hospital services and follow-up care through intensive, community-based case management.
For every firearm homicide, there are three people wounded in a firearm assault who need hospital care1Everytown, A More Complete Picture, 2020. and 30 others victimized with a firearm.2Bureau of Justice and Statistics, NCVS Dashboard, November 19, 2021, https://ncvs.bjs.ojp.gov/Home Emergency departments and trauma centers are prepared to treat physical injuries and medical needs from violent injury but most lack the resources needed to address the mental and societal consequences victims face. Some patients are found to be at a particularly high risk of gun carrying, substance abuse, and high levels of anger after victimization. HVIPs provide a range of mental health, educational, legal, and financial services starting just after a violent injury.
HVIPs are an important gun violence prevention program because firearm re-injury, including death, is all too common:
- One in four adolescent boys and young men injured by guns will be shot and wounded or killed within 10 years following that injury.3Marshall et al “Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database”, 2020.
- Compared to the general population, patients hospitalized for firearm injuries are 30 times more likely to be hospitalized and seven times more likely to die of a firearm injury within the next five years.4Rowhani-Rahbar, et al. “Firearm-related Hospitalizations and Risk for Subsequent Violent Injury, Death, or Crime Perpetration.”, 2015.
- Patients hospitalized for firearm injuries are nearly three times more likely to have a firearm- or violence-related arrest within five years compared to people hospitalized for reasons other than injury.5Rowhani-Rahbar, et al. “Firearm-related Hospitalizations and Risk for Subsequent Violent Injury, Death, or Crime Perpetration.”, 2015.
- Costs related to seven out of ten hospital visits for firearm injuries are borne by taxpayers through Medicaid, Medicare, or government support for hospitals to care for uninsured poor patients.6Coupet et al, “Shift in U.S. payer responsibility for acute care of violent injuries after the Affordable Care Act: Implications for prevention.” Am J of Emer Med 2018: 36(12).
HVIPs have been implemented in hospitals across the United States. They take advantage of an ideal opportunity for intervention in these cases, a teachable moment. There is a small window to engage with the victim and begin to provide a range of services beyond medical that can reduce the chances of the patient becoming a victim or perpetrator of violence in the future.7Johnson et al, “Characterizing the Teachable Moment: Is an Emergency Department Visit a Teachable Moment for Intervention Among Assault-Injured Youth and Their Parents?”, 2007. McBride et al, “Understanding the potential of teachable moments: the case of smoking cessation”, 2003
HVIP participants are significantly less likely to experience a subsequent injury or criminal recidivism and are more likely to have positive outcomes such as employment, school completion, and access to social assistance. As a result, HVIP can save cities money on hospital care, police response, and jail.
There are many successful case studies from around the country:
- The Wraparound Project based in San Francisco demonstrated a six-year violent reinjury rate of 4.9 percent, compared to a 8.4 percent historical control group of violently injured patients.8Catherine Juillard et al., “A Decade of Hospital-Based Violence Intervention: Benefits and Shortcomings,” Journal of Trauma and Acute Care Surgery 81, no. 6 (2016): 1156–61, https://doi.org/10.1097/TA.0000000000001261.
- In Baltimore, individuals who did not participate in the HVIP program were six times more likely to be hospitalized again for a violent injury and four times more likely to be convicted of a violent crime than individuals who received the intervention. Individuals who received the intervention also saw their employment rate double, while employment fell for those not in the program.9Cooper, Eslinger, and Stolley at al., “Hospital-Based Violence Intervention Programs Work”, 2006.
- Oakland, CA’s youth-oriented HVIP found that participants were less frequently placed on probation, arrested or had any criminal outcome during the six months following their injury than youth who did not receive the intervention.10Becker et al, 2004. https://www.sciencedirect.com/science/article/pii/S1054139X03002787
HVIPs should be implemented in hospitals that serve as trauma centers, which are equipped and staffed to provide care to patients suffering from major traumatic injuries like gunshot wounds. This increases the likelihood that a shooting victim will be brought to the hospital for treatment and creates an opportunity for staff to engage the victim.
A sustainable source of funding is necessary for a successful HVIP. This ensures that victims have uninterrupted access to comprehensive follow-up support from case managers and mentors once they are discharged in order to prevent future violence.
Strategy in Practice
If you are interested in starting or supporting an HVIP in your jurisdiction, begin by checking out The Health Alliance for Violence Intervention (The HAVI) directory of established HVIPs to see if there is already a program in your area. The HAVI is a national organization that fosters hospital and community collaborations to advance equitable, trauma-informed care and violence intervention and prevention programs, and is available to provide support and training for the establishment and development of HVIPs throughout the country.
If there is no local program, you can start by convening a meeting with area hospitals, trauma centers, clinics, street outreach programs, and other local stakeholders to explore interest and capacity. Be prepared to share the basics of how these programs operate, as well as how your city may be able to support the work of an HVIP.
Effective HVIPs integrate violence intervention at the start, with case managers conducting a first review and assessment of the violent incident and screening for program participant eligibility. Eligibility is determined by, but not limited to, a specific age range (anywhere between 10 and 35 years) and violent injury resulting in a hospital stay or admittance to an emergency department with an intentional injury.
Following the assessment and screening, case managers discuss conflict resolution strategies and nonviolent alternatives, with the immediate goal of preventing retaliatory violence. Discussions include a safety risk assessment and information on the prevalence of violence and homicide among peers. After being discharged from the hospital, the patient will continue to work with the HVIP case manager, who will aid them in accessing the appropriate social and community-based services, including mental health services, job training, substance abuse programs, and a proper medical follow-up to ensure injuries are being cared for properly.
HVIPs should be implemented throughout the country. Several jurisdictions support entire networks of HVIPs regionally to ensure interhospital cooperation. Repeat injuries are not always treated at the original hospital, but HVIP networks can help ensure accurate follow-up care and referrals.
Insufficient Resources: Inconsistent or insufficient funding and staffing for HVIPs can lead to low rates of participation in these programs. Violent injury often occurs at night or over weekends and if patients are discharged from the hospital before staff are available, the intervention will not be successful.11Smith et al, 2012 “Passing the torch: evaluating exportability of a violence intervention program”
Limited Hospital Programs: Relying on a single hospital in a particular region experiencing high rates of gun violence to sponsor an HVIP may result in participants being missed, as victims might be admitted to different hospitals for new violence-related injuries outside of the original treatment center.12Bell et al.,“Long-Term Evaluation.” Additionally, violently injured patients have a variety of medical issues that occur after their original treatment and may not return to the original hospital of treatment.13Ibid.
Limited Connections to Social Services: Although HVIP starts in the hospital, it is important that the case manager is able to connect victims to services that meet their needs once they are discharged. This can include housing and rental assistance, tutoring and GED programs, mental health and trauma care, and legal aid. HVIPs go far beyond brief interventions such as videos or brochures offered in the emergency department with phone numbers or addresses of social services. While a robust staff will help ensure the success of any HVIP, additional support is needed from the community to support a holistic approach. This should include, but not be limited to, city leaders, social services, neighborhood organizations, and violence prevention organizations. While a robust staff will help ensure the success of any HVIP, additional support is needed from the community to support a holistic approach. This will include, but not be limited to, city leaders, social services, neighborhood organizations, violence prevention organizations, and local universities involved in data collection.
Newsroom & Resources
The Health Alliance for Violence Intervention (The HAVI)
The Health Alliance for Violence Intervention (The HAVI) provides resources, technical assistance, and guidance to hospitals to promote trauma-informed care for communities impacted by violence. Additionally, The HAVI organizes and facilitates collaboration among HVIP member programs in the areas of research, professional development and certification, and policy, and convenes an annual conference for all HVIP and key stakeholders in the field of violence prevention and intervention.
Caught in the Crossfire, a program of Youth ALIVE! and based in Oakland, California, was the first HVIP, established in 1994. Through Caught in the Crossfire, Youth ALIVE! Intervention Specialists meet traumatized young victims of violence at their hospital bedsides to 1) convince them, their friends and family not to retaliate; and 2) offer practical help and a path towards safety and healing. Caught in the Crossfire staff address both the urgent need for violence intervention and the ongoing service needs of traumatized victims as they get back to life, as they confront the sometimes debilitating effects of their trauma. Caught in the Crossfire breaks the cycle of violence. Less than 2% of the shot or stabbed youth participating in the program are re-injured.
San Francisco Wraparound Project
The Wraparound Project (WAP), based at San Francisco General Hospital (SFGH) has served as a HVIP since 2003. After initial assessment, victims who are between the ages of 10-30 years are screened for inclusion. These participants receive intensive, individualized case management services and are provided risk reduction resources. This program has been associated with a fourfold decrease in injury recidivism, compared to previous rates. Additionally, based on presumed costs of hospital treatments and the current return on SFGH’s investment, it is believed that the program saves the hospital approximately half a million dollars per year.
Project Ujima is a multidisciplinary collaboration established in 1996 between the Children’s Wisconsin health care system, the Medical College of Wisconsin, and the Children’s Service Society of Wisconsin. The program is committed to helping stop the cycle of violent crimes through crisis intervention and case management, social and emotional support, youth development and mentoring, and mental health and medical services. Project Ujima’s success working with youth victims of violence is most evident in the recidivism rate of less than one percent since 2004. Those participating in the program avoid becoming victims of further violence. Other successes have included better medical outcomes after injury, increased confidence and self-esteem, connection to peers and others who understand the effects of violence, and improved school, youth, family relationships.