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For Hospitals, Treating Violence Beyond The ER Is Good Medicine And Good Business

BALTIMORE — Ask David Ross to describe an average day on the job. He says it doesn’t exist.

Ross is a violence intervention specialist at the University of Maryland Medical Center. Though he isn’t a doctor, he’s been working at the hospital as part of its Violence Prevention Program for close to 10 years. His team works with patients who are victims of violent injuries — stabbings, gunshots or physical assaults — and who physicians flag as candidates for the program’s assistance.

His challenge is to figure out the factors in their lives that put them at risk of violence. The work he does is time-consuming, and the relationships he builds with these patients can last months and even years.

Do you feel safe at home? Do you have health insurance? A high school diploma? A stable job? Having health insurance or a diploma is no guarantee against violence, but Ross and his colleagues ask such questions to help the team connect patients with programs that might improve their lives and insulate them from the violence that put them in the hospital.

“Some days, it can be emotional. Or it can be gratifying,” Ross said. “I spoke to a patient the other day, and he almost had me crying.”

Sometimes that kind of emotion comes from the devastating things patients have seen, whether it’s the result of a dysfunctional living situation, substance abuse, poverty or other social ills. Other times, it’s because “you thought you made progress — and then there’s a setback.”

Maryland is a pioneer in this type of coordinated effort, having launched its anti-violence program in 1998. Now, about 30 hospitals across the country — from the Children’s Hospital of Philadelphia to the University of Rochester Medical Center in New York — have developed similar initiatives. They follow Maryland’s “wraparound” approach, which involves following up with patients after they leave the hospital, and providing medical and social support to keep them out of harm’s way — by, for example, getting them into drug rehab or education classes for people who have not finished high school. The hospitals are acting on the notion that keeping violent injury from recurring will ultimately reduce their expenses and improve people’s long-term health. In other words, they increasingly view violence prevention programs as both good medicine and good business.

On this particular day, Ross visited seven hospital patients who were being treated for violent injuries. Ross’s job isn’t just to identify the trouble spots in a patient’s life; it also involves moving with the person through the legal and medical systems, sometimes acting as an advocate. The day before, for instance, he had accompanied a mentally ill client to court to make sure the man’s condition was understood by authorities. On such days, he dresses in a suit instead of his hospital uniform: pink scrubs, an outfit that shows that while he doesn’t stitch wounds or prescribe pills, he’s part of a team dedicated to keeping patients healthy.

As experts increasingly view violence as a medical concern, hospitals see it as an opportunity. “There’s been a groundswell of professionals understanding that this is a public health issue,” said Rochelle Dicker, a trauma surgeon and professor at the University of California, San Francisco, who directs the UCSF Medical Center’s violence prevention program.

And the 2010 federal health law supports that interest. It says nonprofit hospitals have to work harder if they want to maintain their tax-exempt status: Among other requirements, they have to formally measure their surrounding community’s health needs at least every three years and implement a strategy to address them.

To this end, a growing number of hospitals, especially those located in areas with high rates of violent crime, are partnering with local organizations to try to reduce neighborhood violence, said Jonathan Purtle, an assistant professor at Drexel University who researches hospitals and violence prevention.

The Department of Justice has been supportive, too. In a 2012 report, it recommended that hospitals become more involved in violence prevention, through counseling patients directly or connecting them with education, gang diversion programs, substance abuse treatment and other social services.

Research shows that, if someone comes in suffering from a gunshot or stab wound and then, after leaving the hospital, returns to the same environment, there are good odds they will be back in the emergency department. In addition, trends and anecdotal evidence suggest people at higher risk for violent injury are likely to face issues such as domestic violence, mental illness or substance abuse. They also often deal with other stressors, like poverty or bad housing. These challenges can result in health problems including lead poisoning and poor nutrition, which the hospital can work to address. Even if they can’t change, for instance, a neighborhood’s crime rate or drug culture, they can help someone get into rehab or find somewhere new to live.

Much of the growth in such hospital interventions has happened in the past five years, Dicker said.

“It’s becoming a more established understanding that this kind of violence is preventable,” said Rebecca Cunningham, an emergency medicine professor at the University of Michigan and associate director of its youth violence prevention center. “And we can have programs that can prevent it, and the hospital and emergency department are really critical locations for this.”

Michigan’s center doesn’t do that same level of outreach and case management as Maryland’s. All patients between the ages of 14 and 20 and from neighborhoods where violence is more prevalent are approached for a counseling session — what Cunningham called a “preventive” intervention.

So far, there isn’t much research measuring these programs’ effectiveness. But the findings available show promise. UCSF found that people who had come to the hospital with a gunshot or stab wound and then participated in the intervention program were far less likely to get injured again after leaving. The number of patients returning with another violent injury dropped from 16 percent to 4.5 percent. And in a paper published last year, researchers estimated that program would save the hospital half a million dollars annually.

That’s crucial. “It’s very important to be able to talk about cost effectiveness” as hospitals look to curb unnecessary expenses, Dicker said.

The University of Maryland‘s statistics are similarly encouraging. Research found victims of violent injury who went through the program were 83 percent less likely to return because of another violent event when compared with those who didn’t participate, said Tara Reed Carlson, who directs the university’s Center for Injury Prevention and Policy. Those who had participated in the program were more likely to have a job and less likely to be involved in criminal activity.

Ross said the work he does — and the change he sees — underscores the value of intensive outreach. The before-and-after contrast is striking. “I’m talking about young guys who haven’t had any guidance,” he said. “That’s rewarding.”

Often, he said, patients stop by to visit, years after they’ve gone through the program. They share new successes, like buying a home or getting married.

“It makes you feel good,” he said. “You’re doing something that’s needed.”

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