ED-based interventions to break cycle among patients presenting with violence-related injuries
June 1, 2015
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Executive Summary
Studies have shown that patients who present to the ED with violence-related injuries are at high risk of being involved in future violent incidents. Consequently, investigators say the ED is an ideal setting to intervene with these individuals with the kind of care and support that will lead them toward a safer path. Helping Hurt People (HHP), a hospital-based trauma support program developed at Drexel University in Philadelphia, PA, has been fulfilling this function at Hahnemann University Hospital and St. Christopher’s Hospital for Children in Philadelphia since 2007, and now the program is being expanded to three other trauma centers, along with a research program aimed at documenting HHP’s effectiveness.
- When a patient presents with injuries from an assault or other form of violence, ED personnel are encouraged to contact the HHP social worker who then follows up with the patient.
- Interventions offered through HHP include a range of social and mental health services such as behavioral health counseling, job placement assistance, help with housing, and educational guidance.
- Program administrators say HHP interventions have reduced symptoms of PTSD, depression, and anxiety, and that it has successfully linked many patients with health insurance and primary care.
- With expansion of the program to three new trauma centers, more comprehensive research is planned to document the program’s effectiveness.
Unique trauma support program shows promise
Emergency providers have so much to do it is hard to justify adding one more task to their already full plates. However, when the right resources are in place, there is increasing evidence that EDs can play a pivotal role in preventing victims of violence from becoming enmeshed in a cycle that brings them or associates back to the ED with similar injuries again and again.
The risk of such repercussions is well recognized at this point. The latest study to take a look at the issue followed a population of adolescents and young adults with a history of drug use who presented to the ED with injuries from assaults. Investigators found that these patients had a 40% higher risk of reporting firearm violence within two years of their initial ED visit than peers who had no history of assault. Further, the researchers report that two-thirds of the incidents involving firearm violence occurred within six months of the ED visit.1
Investigators say these and similar findings highlight the opportunity that EDs have to intervene in a way that will point victims down a safer path, potentially preventing future incidents from occurring. Indeed, some hospitals have already taken steps to identify patients who present to the ED with violence-related injuries and link them with care and support aimed at short circuiting the cycle that leads so many victims of violence to seek retribution or to be victimized again.
Identify patients at risk
For example, Helping Hurt People (HHP), a hospital-based trauma support program developed by the Center for Nonviolence and Social Justice at Drexel University in Philadelphia, PA, has been actively intervening with victims of violence in the ED at Hahnemann University Hospital and St. Christopher’s Hospital for Children in Philadelphia, PA, since 2007.
“We have a program manager and then there are two social workers who are committed to working not just in the hospital but also in the community,” explains Theodore Corbin, MD, MPP, the director of HHP, and an associate professor in the Department of Emergency Medicine in the College of Medicine at Drexel.
Corbin explains that when patients present to the ED with injuries from an assault or another form of violence, emergency personnel are encouraged to contact HHP. “They all have cards and numbers where they can reach our social worker,” he says. “Monday through Friday, between the hours of 9 and 5, are when our staff are on the premises.”
If a victim of violence comes to the ED after these hours, then this will be noted in the electronic medical record (EMR) so that one of HHP’s social workers can follow up with the patient the next day, explains Corbin. “The social worker will come in every day and go through the log to see if there is anyone who has been flagged,” he says. Further, while the ED is the main point for patient identification, HHP also provides information to the hospital’s surgical nurses and trauma surgeons so that they are equipped to refer patients to the program as well.
The range of services and support offered to patients through the HHP program varies depending on what they need. “Someone’s needs could be very minimal because they have other supports in their lives whereby they might just need a simple referral to a primary care physician or a connection with health care,” says Corbin. “Others will have a bit more complexity in their lives and situations, and they will benefit from other services.”
These may include such services such as behavioral health counseling, substance abuse treatment, job training and placement, parenting education and support, housing, and legal help. “What we emphasize is the trauma that people experience, and not just the physical aspects of it, but the psychological and emotional aspects of it as well, and how [these aspects] have impact on a person’s physiology,” observes Corbin.
Clinicians who have experienced or witnessed violence may have some understanding of this longer-term impact, observes Corbin. “I see a lot of this on a regular basis, but I have a support system in place that allows me to decompress, move through, and move on,” he says. “But some of the young people who are plagued with this chronic stress and adversity on a daily basis don’t have support systems in place to help them move past and move through these experiences.”
Collect pre- and post-intervention data
Results from the HHP intervention have not yet been tabulated in a scientific way, but they have been observed, advises Corbin. “What we are noticing is that we are decreasing the propensity to develop PTSD [post-traumatic stress disorder] symptomatology … and we are decreasing symptoms of depression and anxiety,” he says, noting that other more tangible results include connecting patients with health insurance and primary care.
While anecdotal, these results have nonetheless attracted the attention of other hospitals in the area. Indeed, with funding from Philadelphia’s Department of Behavioral Health and Intellectual Disability Services (DBHIDS), HHP is now being expanded to the EDs at Temple University Hospital, The Hospital of the University of Pennsylvania, and Einstein Medical Center, a move that will eventually make HHP available city-wide. Further coupled with this expansion is the opportunity to collect the kind of hard data needed to convincingly demonstrate the program’s effectiveness.
For example, while Einstein Medical Center is still in pre-implementation mode, it is also collecting data about current patients who present to the ED with violent injuries and get usual emergency treatment. “We will then follow up with them at six weeks, six months, and a year to see what kind of health and psychosocial outcomes they are having,” explains James Gardner, MD, an attending physician in the ED at Einstein Medical Center and the champion of HHP for this facility. “And then once the program is actually implemented, we are going to gather the same data on patients … to see if we are actually making a difference in outcomes between before and after we have the program in place, so it is a …unique opportunity to do this kind of effectiveness research.”
This type research is also going on at the other trauma centers that are putting the HHP program into place. “We are implementing the program at these four hospitals and doing the research at these four hospitals, so we should have a pretty big database at the end of the research implementation [to show] how well this works,” observes Gardner. “What we are looking at is a broad array of outcomes that we know are associated with violent injury.”
For instance, Gardner notes that researchers will be looking well beyond the traditional medical measures, such as how well a wound has healed or what changes have occurred in a patient’s disability status. “We know there are a lot of psychosocial problems that go along violent injuries, and that when these predominantly young men present to the ED after they have gotten in a fight or got assaulted or got shot or mugged ... a lot of times that is the tip of the iceberg of a lot of other underlying problems, both for them personally and for the communities they come from.”
Consider psychosocial outcomes
Many of the patients who present with these types of injuries have led traumatized lives, adds Gardner. “Oftentimes when they are coming into the ED, that is not the first time they have been victims of violence, and it is not the first time they have seen violence,” he says. “Their families and their friends have been involved in [violence] and been victims of it, and they have had involvement in the criminal justice system, so we see the presentation to the ED as kind of the index case where we can identify that here is someone who is at risk in all of these different ways.”
In such cases, the visit to the ED may be the only time that these individuals actually come to medical attention, so it is an opportunity to potentially intervene, explains Gardner. “In terms of outcomes, we are looking at everything from rates of PTSD to substance abuse to further involvement in the criminal justice system, either as repeat victims or perpetrators,” he says.
Also on the radar are job and educational-related outcomes. “These are all things that we try to address in the program, and they are all outcomes that we are looking at to see if there is improvement in them as a result of their participating in the program,” observes Gardner.
While HHP has a heavy social-work focus, it does not duplicate any of the services already provided by hospital-based social workers, according to Gardner. “We have excellent ED social work staff and trauma social work staff, but they tend to be pretty thinly spread, and they are focused on fairly immediate needs,” he says. “They can do brief evaluations and referrals, but they don’t really have the time to engage with patients in a more in-depth way, which I know is a frustration for them.”
However, HHP provides the resources and the staff to dedicate much more time on each of these patients, says Gardner. For example, some of the program interventions are designed to address basic, pragmatic needs such as assessing what a patient’s ongoing health and financial needs are, and making sure they have follow-up appointments, transportation, and help with navigating the health system. “These basic [things] can be surprisingly challenging for some of these patients,” notes Gardner.
However, there are also interventions designed to address the underlying psychological issues that often go along with violent injuries. “A lot of these patients have past traumatic experiences going all the way back to childhood,” says Gardner. “They can often have pretty significant PTSD related to the injury that brought them to the ED.”
To address these issues, patients can receive individual therapy as well as weekly group sessions where they will engage with other members of the program, explains Gardner. “One problem with a lot of these patients is that they don’t have a vision for their future,” he says. “There is an assumption that they are going to end up dead at a young age, and that they won’t have opportunities. That can be a self-fulfilling prophecy.”
Develop billing strategies
Corbin estimates that the ED at Hahnemann University Hospital sees about 90 patients a month who present with interpersonal injuries and that HHP connects with at least 50 of these individuals. Gardner is anticipating that the program being developed at Einstein Medical Center will screen several dozen patients every week, eventually connecting with about two dozen patients a month, although there are likely to be seasonal fluctuations in the volume. “The violence that we see really spikes during the summer; it lays off a bit in the winter,” says Gardner.
While most of the funding for the program is coming from DBHIDS, one goal of program developers is to make the program mostly self-sustaining by seeking reimbursement for some of the social work and psychological interventions that HHP delivers.
“We feel like these clinical interventions have similar public health benefits to a lot of other things we do and should be reimbursed similarly,” says Gardner. “One thing which I think is very clear in the literature but continues to be underappreciated as a matter of public policy and health policy is how central mental health is to health outcomes — and particularly in the ED.”
For instance, Gardner points out that there is a mental health component to many of the conditions that emergency providers see every day. “Everything from cardiovascular disease to diabetes to alcohol and drug abuse — all of these things, in one way or another, get tied either directly or indirectly to behavioral health and mental health risk factors,” he says. “I think in some ways we see so much of this in the ED that we almost kind of forget that it is there, but it really is a big component of what we do.”
Gardner says he is very enthusiastic about trying to move ED physicians, ED administrators, and payer mentalities toward recognizing how important mental health issues are to both longer-term outcomes and costs. “If you pay some attention to these issues on the front end, you potentially prevent far larger financial expenditures on the back end, and so that is one thing we are hoping to demonstrate in this before-and-after research,” he explains.
Re-admissions due to subsequent violent injuries, higher rates of substance abuse, further development of mental health issues, and repeat involvement in the criminal justice system are all tremendously expensive outcomes both for the health system and society, stresses Gardner. “Any prevention [of these things] on the front end with what is a relatively inexpensive intervention up front should really be worthwhile, so we are hoping to be able to demonstrate that to government and to payers as well,” he says.
Facilitate referrals
Far from getting pushback, plans for the program at Einstein Medical Center are getting an enthusiastic response from both hospital administrators and emergency providers thus far, explains Gardner. “We all recognize this as an issue and an unmet need,” he says. However, Gardner also emphasizes that program administrators are trying to make referrals to HHP as easy as possible for providers.
“I would like this to be something they think of in the same way as when they refer a patient to cardiology if someone comes in with shortness of breath or orthopedics if they come in with a broken wrist,” says Gardner. “This should be a similar kind of triage and referral process like we do with every other problem that we see in the ED, and I think we are actually going to make it just as easy, if not easier than the referral process for those other conditions.”
Further, while HHP will be based in the ED, the program is really a multi-department effort, says Gardner. “The Department of Psychiatry is involved, the Department of Social Work is obviously involved, and the Trauma Department is involved, so it is [an opportunity] for cross-department collaboration,” he observes. “That is pretty exciting as well — getting people from all their different silos to work together on these patients.”
With four large trauma centers now involved in HHP, researchers and administrators have an opportunity to share best practices in terms of planning and implementing the program. It is also clear that hospitals in other regions are eyeing the approach. Indeed, developers note that a few hospitals in Illinois and Oregon have also moved to replicate the program.
However, even at Hahnemann University Hospital, where HHP has been in place since 2007, the model requires ongoing education and reinforcement. “On a quarterly basis we do in-service sessions for the nurses, both in the ED as well as those who are in the trauma unit and on the med-surge floors. Then also for the physicians we do brief presentations about the work, and often we bring in some of the young people that are in involved in the program and let them talk to the physicians about their experiences,” says Corbin. “Especially at this time when [there is such a strong focus on] patient satisfaction, it is good feedback for physicians to know what worked well and what didn’t.”
REFERENCE
- Carter P, Walton M, Roehler D, et al. Firearm violence among high-risk emergency department youth after an assault injury. Pediatrics 2015;135: 2014-3572.
SOURCES
- Theodore Corbin, MD, MPP, Director, Helping Hurt People, and Associate Professor, Department of Emergency Medicine, College of Medicine, Drexel University, Philadelphia, PA. E-mail: [email protected].
- James Gardner, MD, Attending Physician, Emergency Department, Einstein Medical Center, Philadelphia, PA. E-mail: [email protected].
Emergency providers have so much to do it is hard to justify adding one more task to their already full plates. However, when the right resources are in place, there is increasing evidence that EDs can play a pivotal role in preventing victims of violence from becoming enmeshed in a cycle that brings them or associates back to the ED with similar injuries again and again.
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