Take advantage of opportunities to reduce ED violence, recidivism among children and young adults
Take advantage of opportunities to reduce ED violence, recidivism among children and young adults
On-site community outreach workers can link victims of violence with needed resources
In the wake of the horrific massacre of young children by a disturbed gunman at Sandy Hook Elementary School in Newtown, CT, there has been a national discussion about what the country can do to curb such senseless acts of violence. While much of the focus has been on firearms legislation, there is also a renewed interest in steps that communities can take to prevent single instances of violence from becoming repetitive cycles in which physical and psychological damage is spread from victim to family to community in an ever-widening circle.
When violence is viewed in this way, it becomes clear that EDs are uniquely positioned to intervene in a way that can have lasting impact — not just on the victims of violence, who are often teenagers and young adults, but on the larger society as well. Statistics from the U.S. Centers for Disease Control and Prevention reveal the scope of the problem, as well the potential opportunity that EDs have to intervene: Roughly 700,000 people between the ages of 10 and 24 were treated in EDs for injuries caused by violence in 2009.
While meaningful intervention requires training, resources, and commitment, evidence is growing that ED-based efforts can produce measurable results in terms of violence reduction and reduced health care utilization.
Consider the experience of Boston Medical Center (BMC), which partnered with community activists to create the Violence Intervention Advocacy Program (VIAP) in 2006. “In our hospital, we see 72% of the penetrating trauma in Boston — the stabbings and shootings,” explains Thea James, MD, an emergency physician at BMC and the director of VIAP. “There had been a resurgence of this violence in Boston, so the mayor came to our hospital and asked us to do something about it, and the city supported us with a grant.”
The idea behind VIAP was to equip victims of violence with the services and support they need so that they could return to their communities and avoid repeat instances of violence. It was a tall order, but James observes that between 2007 and 2012, the program has reduced recidivism among gunshot wound victims by 30%, and recidivism among stabbing victims is down about half. In fact, the program has been so successful that the governor has asked BMC to disseminate the model to other hospitals in Massachusetts that see high numbers of shooting and stabbing victims, explains James.
Provide “trauma-informed care”
When the program began, it just consisted of James and two patient advocates that she hired from the community. However, the VIAP program has since evolved and expanded to include a program manager, who is a licensed clinical social worker, a family support coordinator, a data research manager, and two patient advocates, or, as some people call them, “interventionists,” says James. “We also have another group of people we work with: the community response team. They provide mental health services for our clients.”
The way the program works is whenever a victim of violence presents to the ED, the VIAP team is alerted to intervene. “Not every kid that we see is involved in negative behavior. Some people have just been caught in the crossfire, but it is an opportunity to intervene no matter what background they have,” explains James. “The first thing we do is develop a rapport with them and try to assess them for safety. We create a needs assessment for them in terms of what they are going to need throughout their [ED stay] or hospitalization and once they are discharged.”
The VIAP team also immediately calls on the community response team to provide mental health services at the bedside. “We found out very early, during the first year of the program, that when one of these kids is injured, it not only affects them but everybody in proximity to them, so we also offer the mental health services to their siblings and their parents as well,” says James, explaining that these services will continue after discharge as well.
Key to the VIAP approach is a specific method of talking with people that James refers to as “trauma-informed care.” “You want to create an environment of safety and empowerment for the patients, and more than anything else, you want to avoid re-traumatizing them,” she says.
This is important, says James, because people inadvertently re-traumatize victims of violence all the time, she says. “A lot of people think if you get stabbed or shot you must be a bad person, and sometimes they don’t understand the manifestations of trauma.”
For example, James says that when a nurse or physical therapist finds that a patient is apparently unwilling to do what is asked, and is instead lying on a bed with a sheet over his or her head, they may decide that the patient lacks respect or doesn’t care about him- or herself or anyone else. However, this type of behavior can actually be a manifestation of trauma. “Oftentimes, when we have been up to intervene with this type of patient, when we look under the sheet, the kid is in a fetal position with tears streaming down his face,” she says. “When kids are growing up in unsafe environments, one of the things they do to adjust to the environment is they become hyper-vigilant, and they sometimes become self-destructive.”
The patient advocates have been specifically hired from these same communities so that they will have an understanding of what many of these patients are up against, says James. “We felt if we were going to provide services for these clients, the patient advocates needed to be able to understand and relate to them,” she says.
Collaborate with community groups
Many victims of violence have deficits that are obvious. They may not be able to move an arm because they have been maimed in some way, or they may have visible scars, says James. “When they are young, say 14 or 15, they may not want to go to school anymore, so we have to address all those types of problems,” she says.
James explains that the biggest issues are mental health, safety, and housing. “Many times, the parents don’t want to live where they are living anymore, so we have to arrange for emergency housing,” she says, noting that many also require education, life skills training, and job training. “We have developed connections with a lot of community-based organizations that provide various different types of services,” she says. “We have one place that does weight-lifting, but it does a lot more than that. It also helps clients with life skills training, finding jobs, and teaching them how to do resumes.”
Many of the people involved with these community organizations already know the patients who have presented to the ED with violence-related injuries because they have already been working in the higher-risk neighborhoods trying to prevent problems from erupting. “When someone gets injured and comes in, they can often provide us with more information about the person than we already know,” says James. “It helps our advocates to be able to work with the patients and provide appropriate services. And because our advocates already live in these neighborhoods, they often know the patients, too.”
Document the work performed
While VIAP is now firmly ingrained in the hospital, with funding support from several different sources, including the Boston Public Health Commission, the State Department of Health, the Boston Foundation, and the Robert Wood Johnson Foundation, staff education about trauma-informed care requires constant reinforcement. “People have no idea about how patients wind up in these [violent] predicaments, and they certainly don’t know what causes the reactions that people have after they get in here,” says James.
To make sure that providers and staff stay informed, James gives numerous presentations about trauma-informed care, but she would like to develop an educational program around the topic that she could take from unit to unit, and that could be required of all new hospital employees. “It is important to disseminate this information,” she says.
She also has advice to offer ED managers and providers who are interested in developing a VIAP-like program of their own. First, James has learned that it is important to adequately prepare hospital staff before moving forward with any changes. She did not do that when VIAP was first introduced, so it was a hard lesson.
“Our psych nurses in the ED are normally the people who serve as liaisons between the physicians and the family ... and when our patient advocates came in and started doing some of that, a few people thought their jobs were being replaced,” recalls James. “I didn’t let them know that the patient advocates were coming and what their role was going to be. The roles are completely different, but I didn’t prepare them.”
There was also a negative reaction from some hospital staff members who thought the patient advocates were acting too much like social workers without a degree because the staff members didn’t understand the peer-mentoring approach, explains James. “All of that stuff has long since been ironed out, but I could have easily oriented them about the program and avoided some of the issues that came up in the beginning,” she says.
If you will be utilizing patient advocates from the community, James emphasizes that it is equally important to prepare them for the hospital environment, and to get them immediately accustomed to documenting their work. “From the very first client, have a data collection system in place to document everything,” she says. Assembling a program database is very difficult when you get a late start, adds James.
Intervening in a meaningful way with the victims of violence is very hard work, acknowledges James. But she stresses that emergency settings are the ideal place to make a connection with these individuals. “The ED is the first point of contact,” she says. “Every program is different, but we try to have a 100% capture rate. Very few people slip through here without coming into contact with us, so our level of accountability for our advocates is pretty steep. We are very serious that no one should come through here and not interface with us.”
Establish whether there are risk factors
Denver Health Medical Center has also taken steps to intervene with young victims of violence who present to the ED through its At Risk Intervention and Monitoring (AIM) project, launched in June of 2012. As with BMC’s program, AIM relies on a team of community outreach workers from Denver’s Gang Rescue and Support Project to establish a rapport with patients who have been victimized by violence, link them with needed social services, and guide them toward less risky lifestyles and behaviors.
While the program is just getting started, there is already some evidence that the approach is having an impact on patients, explains Sara Muramoto, the program manager of AIM. “I did a brief measurement of the kids we are actively case managing ... and none of them have come back to the hospital,” she says, noting that recidivism in the ED is the primary metric she focuses on. “If they are coming in for a violent injury, they are going to be coming through the ED.”
Currently, the outreach workers are only on-site in the ED between 11 p.m. on Saturday to 5 a.m. Sunday morning — the period when the ED receives the highest volume of violent injuries among the young people AIM targets, between the ages of 10 and 24. “We go room to room and talk to people. Even when someone does not appear to be at risk, we still go in and talk to them as long as they are in the target age range because one thing that a lot of people are unaware of in the city is victim assistance,” explains Muramoto. “So even if it is a one-time visit, we will ask them how they are doing and find out what their needs are.”
Once an AIM representative begins conversing with a patient, he or she can establish whether there is any gang involvement or other risk factors, says Muramoto. “What social factors brought them there that night? Are they in school? Do they feel safe going home? You try to address all of those things,” she says. “But when we are not in the ED, it is up to the staff to call us.”
Muramoto says she has had everyone from doctors and nurses to clerks and social workers call her about patients who have presented to the ED. “The entire hospital has my personal cell phone so they can reach me at any time,” she says.
Don’t expect quick results
The initial bedside interaction between an AIM outreach worker and a patient in the ED gets the process started, and there is always at least a follow-up call to the patient after discharge. “Patients who are more at risk than others will definitely receive in-person contact, and those patients who are at very high risk will receive ongoing case management,” explains Muramoto. “When patients are discharged from the ED, we always make sure that we get a phone number for them and usually an address as well because many times these patients are not very good at calling back.”
While most patients indicate that they want help, many of them struggle to make changes in their lives, says Muramoto. “What is lacking for most of these people is a stable home,” she says. “They don’t have anyone who really cares for them, so once they start seeing that our outreach workers are going to be there consistently for them, we start to see a difference in their behaviors.”
This kind of follow-up is labor-intensive and difficult, but even modest reductions in recidivism to the ED can result in huge cost savings to the hospital, although it takes time to reap the full benefits of violence prevention, says Muramoto. With the AIM program just reaching the one year mark, it is still too early to gauge any meaningful impact on recidivism or cost savings.
However, emergency providers are happy to have added resources when dealing with these often difficult cases. “These types of patients typically come in with their defenses up. They cuss at the staff, they’re upset, and they’re scared,” says Muramoto, noting that it is difficult to show respect for someone who is yelling at you, especially when you are worried about your own personal safety. With their established ties to the community, the outreach workers can help to de-escalate these types of situations, she says.
Take advantage of training resources
One goal of the AIM program is to make sure that physicians and nurses pick up on signs that a patient may be at risk. “When you are in an inner city, safety-net hospital, almost all of the kids that come in fit the description to some extent, but I don’t think our health care staff necessarily realize that all the time,” observes Muramoto. “I would say about a third of the clients that I have been called in on were not in the ED for a violent injury. But when the physicians started talking with them, they realized there was something preventing these patients from living a normal life or taking care of themselves medically.”
Muramoto provides ongoing training sessions to the medical staff about gang activity in the Denver area, and how to pick up on signs that there may be something beside a medical complaint that brought a patient to the ED. Nurses can earn continuing education credits for attending the sessions, and Muramoto is working on enabling physicians to earn continuing medical educational credits as well.
The community outreach workers also require training. They’re not social workers, although many of them have received schooling in human services-related fields, says Muramoto. Before working one-on-one with patients, these workers typically follow a senior case manager in the hospital. Then they begin working in the community. As time goes on, the workers will have multiple opportunities to take advantage of training sessions on a multitude of topics, ranging from cultural competency and substance use to motivational interviewing and crisis intervention.
With the vast resources available through the hospital and the community, Muramoto says it is easy to arrange these training sessions. “We can get a psychiatrist to talk to us about mental health disorders, and we can get a SANE [sexual assault nurse examiner] nurse to talk about sexual assault or sexual abuse,” she says. There is an ongoing learning curve of new breakout sessions dealing with such topics as how to treat post-traumatic stress syndrome and how to connect young victims of violence with mental health services. “That is usually the biggest obstacle,” adds Muramoto.
The National Network of Hospital-based Violence Intervention Programs, which was formed by BMC and a handful of other programs in 2009, is a continuing source of new practices and ideas for training. “I do monthly calls with the group to discuss updates and find out about new ways that programs are running training sessions,” says Muramoto. (See source box for contact information, below.)
Hospitals and EDs that are interested in establishing a violence prevention program should consider partnering with a community organization that already has deep ties to the neighborhoods most impacted by violence, advises Muramoto. “I wouldn’t have known where to start on my own, but working with the [Gang Rescue and Support Project], I have been able to see what they do,” she says.
There is no question that it is problematic to just have the community outreach workers in the ED one night per week. “We have seen about 180 kids so far, and I have made the first contact on about 160 of them,” acknowledges Muramoto. But she is working with the hospital to expand the program so that an outreach worker can be on site in the ED every evening.
Sources
• The National Network of Hospital-based Violence Intervention Programs, Philadelphia, PA. Website: www.nnhvip.org.
• Thea James, MD, Emergency Physician and Director, Violence Intervention Advocacy Program, Boston Medical Center, Boston, MA. Email: [email protected].
• Sara Muramoto, Program Manager, At Risk Intervention and Mentoring, Denver Health Medical Center, Denver, CO. E-mail: [email protected].
In the wake of the horrific massacre of young children by a disturbed gunman at Sandy Hook Elementary School in Newtown, CT, there has been a national discussion about what the country can do to curb such senseless acts of violence.Subscribe Now for Access
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