Hospitals work to intervene, break the cycle of violence
He was a healthy 15-year-old boy living in St. Louis, wasn’t in a gang, got good grades and stayed out of trouble. But violence swirled around him, and the teen was so fearful of being shot that he contemplated suicide, with the thought of ending life on his own terms. Less than a year later, his fears came true. He was murdered.
That was in 2009, and his death was a crystalizing moment for Margie Batek, the supervisor of social work at St. Louis Children’s Hospital. She knew that her institution had to start doing more to prevent that same feeling of inevitability among inner-city kids.
“Whether he saw something, whether he’d been threatened, whether it was just his feelings and his fears because of all the gunshots in his neighborhood — I don’t know what made that young man think that, but we have to do something,” she says. “This is a child who is willing to take his own life, feeling like that’s the only way he has any control over his own death, which [a lot of these kids] seem to feel is inevitable. And in his case, it was.”
Fast forward to today, and the hospital is in the fourth year of a program that connects youth ages 8-19 who have been shot, stabbed or assaulted with peer mentors who help them break the cycle of violence — statistics show that victims of violence may go on to perpetrate violence themselves. The goal is to save at least half of the lives of children who show an interest in and commitment to the program, but Batek acknowledges she’d settle for one-quarter “while we figure out what we can do to engage more.”
Related article: Community violence’s burden on hospitals
“We will not save them all. I’m not delusional. I’m very well-aware that there will be a great percentage of these kids who will refuse the service,” she says.
Addressing community-based violence is a key concern for America’s hospitals. Each year, more than 55,000 individuals die from violent incidents, and another 2.5 million are injured, according to the Centers for Disease Control and Prevention. Beyond the injuries, there are behavioral health consequences stemming from violence — post-traumatic stress, depression, anxiety and substance abuse — the American Hospital Association notes in its 2015 report “Hospital Approaches to Interrupt the Cycle of Violence.”
More often than not, hurt people hurt people, experts say. Being involved in a violent incident greatly increases an individual’s chances of becoming a perpetrator of violence in the future or suffering further harm from violent acts. One notable study in the 1980s at Detroit’s Henry Ford Hospital found that about 44 percent of young people who were hospitalized for a violent injury returned to the hospital with another serious injury within the next five years. Meanwhile, about 20 percent eventually died due to violence.
That’s why, when a patient is laid up in a bed recovering from being shot or stabbed, hospitals should see it as a “golden moment,” says Linnea Ashley, training and advocacy director with Youth Alive, an Oakland, Calif.-based nonprofit group that works with hospitals to instill leadership traits in adolescents and prevent further violence. As an inpatient, a person is in pain and fearful but is also much more receptive to guidance that might keep him or her from retaliating and continuing the cycle.
There is a growing movement in the hospital field to build upon these ideas and spread similar intervention programs to other institutions. Youth Alive, along with six other charter members, helped to launch the National Network of Hospital-based Violence Intervention Programs in 2009 with funding from Kaiser Permanente’s community benefit program. The network gives trauma surgeons, emergency department doctors and hospital leaders a chance to share best practices and work together to overcome roadblocks. Today, there are 35 such programs across the country, and interest continues to grow.
Barnes-Jewish Hospital in St. Louis is one institution joining the interventionist movement. Seeing the program's success at St. Louis Children’s Hospital, Barnes is now working to extend its Victims of Violence Program to the adult population by providing mentors to young adults ages 20-25.
Launching these programs can be daunting. Typically, insurers don’t reimburse for hospital-based intervention programs, and hospital leadership must be convinced, since other priorities compete for resources. But Kristen Mueller, M.D., an emergency medicine physician with Barnes, says hospitals can either invest in these programs early on to avoid recidivism or pay a much higher price when a patient comes back needing complex surgery for gunshot or stab wounds. “The truth of it is, we are already paying for their care, even the uninsured ones,” she says. In 2016 alone, for instance, hospitals spent $752.4 million on unreimbursed or underreimbursed care for victims of violence, the AHA noted in a July report.
“These programs pay for themselves, usually within six months, and can have millions of dollars in savings in direct costs to the hospital and exponentially more to communities,” Mueller says. “So, I’ve got a lot of hope that this is our first big step toward trying to turn the tide on this in St. Louis.”
Children first
St. Louis Children’s Hospital was able to overcome that initial funding concern through a $300,000 private grant for the program's first two years. That was used in 2014 to hire two clinical social workers who have served as mentors for kids, as well as to buy laptops, cellphones and other supplies.
Those eligible for the program are children ages 8-19 who live in the city or county of St. Louis and who are being treated at SLCH for violence-related injuries. Entry starts in the ED when a social worker approaches the child and his or her family about possibly being linked up with a mentor. If the child and family agree, the mentor quickly contacts the family during that key “golden moment” — the first 24 hours after the incident — and visits them at the hospital, or at home if they’ve been discharged.
Kids are given the phone numbers of their mentors, who are on call 24/7 in case of an emergency. From there, the two parties, and sometimes the parents as well, meet regularly for up to one year to establish goals and come up with a plan to avoid further conflict. There is no set number of meetings required, as needs vary based on each child, but SLCH aims to conduct at least six visits with each child.
The hospital encourages children to tackle at least three goals with the mentor during the year. These might include trying to get into college, landing a job or overcoming a disability, Batek says. Along with that, the mentor also meets with the child's parents, if they’re willing, to work on positive parenting, and the mentor also might transport the child to court or a follow-up doctor’s appointment.
One thing Batek learned early on is that the mentor-child relationship can’t be quick and easy if it's meant to make a real impact on a patient’s life.
“Fast and cheap does not work. They’ve spent their lives getting entrenched in behaviors that you need to change, and you cannot change those behaviors overnight,” she says. “It will not work unless you’re willing to invest the time in it. If there’s one thing I learned from the initial pilot, it’s that you cannot shortchange these kids. You’re not going to have the impact you’re looking for if you don’t give them the time.”
After finding success in those first two years of the program, Batek was able to convince St. Louis Children’s to provide funding beyond the initial private grant, which was used to hire two more social workers. That helped to clear the backlog of kids waitlisted for the mentor program. Those involved are taking it year by year in funding requests with hospital leadership.
Batek says that those who complete the program have a recidivism rate of less than 1 percent, while those who do not show a 20 percent recidivism rate. A number have died, she says.
In the community
Tyrone Ford, one of the four social workers, says that none of the individuals he has mentored has died or returned with an injury resulting from violence. Ford believes that his work is “just as important as [that of] a doctor who’s removing a bullet from an individual who has been shot” and urges hospital leaders to make the small, up-front investment required for interventionists to avoid hefty, down-the-road costs for complex surgery and, sometimes, loss of life.
“How do you address community violence without being in the community?” Ford says. “And so, for Children’s, we are in the community, we go into these neighborhoods, we take our own vehicles out, and we put our own lives at risk to save someone else.”
Of course, St. Louis Children’s can’t save lives without the consent of parents, who often are wary of the mentorship program’s intrusion into their lives. That’s why the hospital is hoping to hire one or two laypeople from the community to build relationships with parents and persuade them of the program’s merits, Batek says.
It's also working on partnerships with adult hospitals in St. Louis to extend the program to people up to age 25. But beyond intervention, Barnes-Jewish Hospital’s Mueller says that hospitals must continue to seek ways to move upstream and prevent violence even before the first encounter — be it through getting community members into stable housing, helping them to obtain jobs or aiding them in acquiring food. “The problem is bigger than just being in the path of the bullet,” she says.
“This isn’t just a city problem, it’s a societal problem,” Batek says. “Anyone who’s passing through this city has an investment in making sure that they’re safe when they’re in it. I’m not saying this is the only answer, but this seems to be a pretty good answer to keep them from coming back to the emergency room shot or stabbed or beaten, or in jail.”
Marty Stempniak is a freelance writer based in Chicago.
Hospitalizations, uncompensated care by payer type
| Total hospitalizations | Un/undercompensated cost (millions) | |
|---|---|---|
| Private insurance | 59,997 | $0 |
| Medicaid | 70,096 | $134.5 |
| Medicare | 43,963 | $123.1 |
| Uninsured | 18,276 | $494.8 |
| Total | 193,332 | $752.4 |
A total approach
While this story is focused on secondary and tertiary prevention after a violent incident has occurred, the American Hospital Association believes that an even broader, multilevel approach is necessary for violence prevention and intervention.
Primary prevention
- Teaching problem-solving and decision-making skills.
- Positive parenting.
- Anti-bullying and conflict resolution.
- Vocational training.
- Stable housing and social services.
Secondary prevention
- Emergency medical care and trauma services.
- Staff trained to recognize trauma.
- Screening for violence exposure.
- Trauma-informed care.
- Case management to facilitate behavior change.
Tertiary prevention
- Long-term wraparound case management.
- Behavioral health and social services.
- Access to safe and healthy environments.
Trustee takeaways
In its 2015 guide, “Hospital Approaches to Interrupt the Cycle of Violence,” the American Hospital Association details a nine-step process that organizations can take to begin intervening.
Experts note that not every community will require a hospital-based, violence-intervention program. But it’s important to take the first step by deciding whether you have a problem and beginning to discover its causes. Julia Resnick, a senior program manager with the AHA’s Association for Community Health Improvement, says any hospital that wants to begin tackling population health should include questions about the prevalence of community violence.
“To keep people well and prevent illness and injury, then you have to think outside the four walls of the hospital and address the social determinants of health," she says. "As we continue along the population health path, communities need to consider how violence impacts health — and not just gang violence or street violence, but also interpersonal violence that might not be so readily apparent. Exploring the types of violence a community experiences can help them understand the root causes of the violence and take steps to prevent it.”
These are the nine steps to follow:
- Define the problem.
- Pinpoint risk and resilience factors.
- Identify community partners.
- Prioritize needs.
- Determine the target population.
- Identify resources.
- Assess the hospital’s role.
- Plan interventions.
- Measure results.
See the AHA's latest news and resources on combating violence.