The impetus to launch a hospital-based anti-violence program usually doesn't come from CEOs concerned about their local communities or from an overworked social worker on the hospital staff.
Hospital-based programs among the options
In most cases, experts say, it starts with a trauma surgeon who is fed up with repeat trauma visits and sees that social norms in violent communities are essentially undermining the advances in medical science by returning ever-more victims for all those whose lives are saved on the operating table.
“I think the time is right for us to get even more involved as a profession,” said Robert Barraco, associate director of trauma at Lehigh Valley Hospital in Allentown, Pa., and chairman of the Injury Control & Violence Prevention Committee of the Eastern Association for the Surgery of Trauma. “We certainly have an ethical responsibility to participate in prevention efforts through our trauma services, and I look forward to more and more of these programs popping up across the country and becoming successful and producing more data.”
But violence prevention programs tend to be labor-intensive and difficult to classify in a hospital's organizational chart. When deciding to start such a program, one of the earliest decisions to make is whether to implement a program that is hospital-based or hospital-linked.
In the former category, the caseworkers who make first contact with the victims receive paychecks from the hospitals and are part of the medical staff. One major advantage of this approach, observers say, is that employees don't have to worry about violating the privacy rules in the Health Insurance Portability and Accountability Act of 1996. Hospital workers can walk around freely inside the facilities and don't have to worry about getting consent forms signed before reviewing medical charts or talking with patients.
However, hospital employees may work regular business hours and can't respond immediately during peak trauma times. Research from CeaseFire, an organization committed to reducing shootings and killing, shows that the most common time its workers respond to a violence victim is 2 a.m., and the most common day is Sunday.
In contrast, hospital-linked programs involve partnering with community-based groups like CeaseFire or Caught in the Crossfire, which have teams of hospital-response interventionists that maintain relationships with trauma staff and are accepted as part of the trauma environment. In that model, the hospital establishes a main point of contact with the community group, whether that's a trauma surgeon, a social worker, an American College of Surgeons-verified injury prevention coordinator, or even a hospital chaplain, who then notifies the group of a need for an interventionist once consent is given. But such groups won't form partnerships with hospitals just because the hospital is willing; the affiliation has to come on the right terms or it won't be struck, as has happened.
And then there is the little matter of payment. Regardless of design, money will be needed to support the program. No one interviewed for this piece was aware of a single program, either linked with or based in a hospital, that is wholly funded out of a hospital line item in a budget on a regular basis.
Rather, the funds come largely from grants. The national network recommends hospitals pursue grant funding from private sources like the Robert Wood Johnson Foundation, United Way, foundations for insurance companies like Blue Cross and Blue Shield, as well as state- and community-based foundations and individual charitable donors. Sources of public funds include city and state public health departments, the U.S. Justice Department and an alphabet soup of federal acronyms like NIH and HRSA—the National Institutes of Health and the Health Resources and Services Administration.
Project Ujima in Wisconsin costs $750,000 a year for a staff of eight full-time workers and all expenses; half of the funding comes from a grant from the Wisconsin Justice Department. The Shock Trauma Center at the University of Maryland Medical Center's Violence Intervention Program costs $290,000 for six full-timers, all of which comes from grants and philanthropy, except for the director's salary. The Violence Intervention Advocacy Program at Boston Medical Center costs about $200,000 and is paid for by various grants, plus a director's salary paid by the hospital and out-of-pocket expenses covered by program staff. Philadelphia's Pennsylvania Injury Reporting and Intervention System, whose outside staff and hospital-based employees did both case management and program evaluation, cost $1.3 million per year.
Yet at the very time that joblessness is rising and the number of vacant buildings is growing in urban communities—both of which are predictors of community violence—funding is drying up as fast as new private and government grant programs appear.
In Massachusetts, the poor economy has claimed two of the five programs that were established with state grants to replicate the program at Boston Medical Center. In Wisconsin, Project Ujima was put in jeopardy last year when the hospital foundation could not raise enough donations to support the half of the program that is not supported by government grants, prompting hospital officials to move it into their general fund for the time being. PIRIS saw all of its funding vanish.
Thea James, assistant professor of emergency medicine and director of the Violence Interventional Advocacy Program at Boston Medical Center, said hospitals bear responsibility for the violence in their surrounding communities by discharging at-risk patients without even attempting meaningful intervention.
“We have every hope that this will become a hospital line item,” said James, an unabashed proponent of such programs. “Not addressing these issues, we are complicit in the perpetuation of it.”
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