Some Hospitals Boost Health by Preventing Violence, Attacking Social Determinants | Healthcare of Tomorrow

Truman Medical Center Hospital Hill in Kansas City, Missouri, embeds so-called violence interrupters into its trauma team, whose job is to quell urges of retaliatory violence among shooting, stabbing and assault survivors and the victims’ social circle. The golden hour after a bleeding or injured victim is rushed to the trauma unit is when these nonmedical peacebrokers can make the biggest impact on reducing further acts of violence in the city.

“That first hour is when we want to be there,” says Rashid Junaid, violence prevention manager with the Aim4Peace Violence Prevention Program, who oversees a team of trained violence interrupters who get called immediately by trauma staff on the “peace” line to counsel victims of intentional violence.

“We’re dealing with the patients and the family and anyone else who may want to retaliate,” Junaid notes. “We buy time, talking them down and helping them to understand the consequences of their actions.”

The goals of the hospital violence prevention program – a partnership between Truman and Aim4Peace – include reducing retaliation and re-injury, as well as promoting positive alternatives to violence. The premise: include so-called “credible messengers,” individuals trained in conflict resolution and mediation and who come from the city’s toughest neighborhoods and have experienced violence, as part of the hospital’s trauma response unit to prevent more victims showing up in the trauma unit.

By several measures, including a citywide homicide rate that has dropped by 28 percent in recent years, the program has been successful.

Aim4Peace relies on mapping of hot spots to help prevent violence in the Kansas City, Mo., area.Courtesy Aim4Peace

“We’ve seen a drop in penetrating trauma,” reports Teresa Lienhop, director of trauma services at Truman Medical Centers. Between 2012 and 2014, the percent of trauma patients stabbed, shot or who present with intentional, penetrating wounds has fallen from 31 percent to 25 percent. That’s about one a day versus multiple per day, notes Truman trauma surgeon Dustin Neel.

“They’ve proven to the hospital they are very valuable,” Neel says of the Aim4Peace workers. For example, many patients treated for such wounds either have no insurance or covered by taxpayer-funded programs. As hospitals take on more financial risk, carrying the financial burden of costly treatment frays the ability of safety-net hospitals like Truman to meet their missions.

Health care reform is changing how hospitals and health systems view and address a community’s health. Through financial carrots and sticks, the Affordable Care Act attempts to turn a system that has rewarded the provision of services to treat illness into one where providers will prosper by keeping people well and preventing disease.

Addressing issues such as violence, hunger, housing and education have more of an impact on people’s health than the medical services hospitals deliver. Studies show that behavior and environment account for about 70 percent of a person’s health outcomes, while medical care accounts for about 10 percent of a person’s health. Yet, the lion’s share of the nation’s health spending goes to medical treatment rather than to prevention. That’s slowly changing.

The result: hospitals experimenting with care-delivery transformations, including collaborating closely with community doctors, forming accountable care organizations (ACO) and getting paid based on keeping people well, not just treating the sick. Still, others such as Truman, Harlem Hospital Center and other New York City Health and Hospital Corporation (HHC) facilities, and Bon Secours Richmond (Va.) Health System are taking a bigger bite of the apple by teaming up with neighborhood activists, businesses, nonprofits and others,in taking on root causes of health, such as violence, food and poverty.

Treating Violence as a Contagious Disease

Truman’s violence prevention program started in 2008, after Kansas City leaders sought solutions to body counts that perennially surpassed the 100 mark. A city-appointed commission recommended tackling violence from a public health perspective, like a contagious disease, rather than through strictly a law-enforcement lens. Today, more than 45 organizations – counting city schools, the police department, faith-based organizations, nonprofits and civic associations – work to support the Aim4Peace effort.

While Aim4Peace has several elements, the partnership with Truman “is the anchor,” observes Tracie McClendon-Cole, Aim4Peace’s director and community justice program manager in the City of Kansas City (Mo.) Health Department. “They are probably our strongest champion. We couldn’t be as successful if we did not have our champions in the trauma unit.”

Besides reducing the number of homicides in Kansas City by 28 percent between 2010 and 2014, the Truman program has played a role in the plunging homicide rate – a 70 percent cut – in the city’s East Patrol section, traditionally one of the city’s most violent communities. The area encompasses nearly one-tenth of the city and home to a community blanketed by Aim4Peace’s conflict resolution, mediation and other violence prevention efforts.

“I feel this is one of the best programs we have here at Truman,” says Mickie Keeling, Truman’s trauma research nurse and the liaison to Aim4Peace, speaking of Truman’s violence prevention program. After examining violent crime patterns in the city, public health officials saw retaliations and arguments fueled homicides and certain assaults. “We can’t afford not to have this program,” Keeling notes. Adds Neel: “If you didn’t have Aim4Peace, the cycle of violence never gets broken.”

The program has expanded since 2008. Initially, Aim4Peace workers saw only gunshot victims, had to be screened through security and had to get upfront patient consent, resulting in too many victims not getting timely visits. Today, any victim of intentional, penetrable violence gets a visit from a violence interrupter, who carry hospital badges and are known widely around Truman. Implied consent makes it easier for workers to reach victims and loved ones in that golden hour. Aim4Peace expects to soon expand the program to another area hospital.

Aim4Peace workers canvass areas in Kansas City, Mo., to help reshape
community norms and expectations around violent behavior.
Courtesy Aim4Peace

But an initial visit by a violence interrupter often is not enough to sway people from retaliatory violence. “They continually see the patients through the hospital stay,” Lienhop says. Violence interrupters “try to build a trusted relationship with that individual,” says Jamal Shakur, an Aim4Peace violence prevention supervisor. That often means maintaining relationships long after a hospitalization, from attending funerals for victims to “going to a family’s home, bringing them food, praying with them,” he says.

“We want to make them a success story,” says Junaid of the surviving victims. That means helping otherwise disadvantaged and disenfranchised individuals “feel connected to the community.” Aim4Peace workers may help them get a driver’s license, connect them with job training, help stabilize their housing situation or hook them up with mental health services.

Research shows individuals who are exposed to consistent violence, either in the home or community, can begin to process the experiences as normal and desensitize individuals. Stress and internal conflict can lead to aggression – exacerbating the violent problem – and other problematic behaviors, including substance abuse and disordered eating habits. Violence makes it hard to feel safe, leading to anxiety, depression, less physical activity in communities and social isolation, all impacting health.

“Trauma’s impact on inequities is huge and on health disparities as well,” McClendon-Cole says. The partnership with Truman is trying to break that and take other steps to prevent violence. To that end, Truman administrators have hired a trauma outreach coordinator who trains police, teachers and others in the community about trauma-informed care in efforts to better understand trauma and to react more supportively of people who may have been impacted by trauma.

“Increasingly, hospital systems are providing health through a larger lens,” says Susan Kansagra, HHC’s assistant vice president of population health. At three of its New York City hospitals, the safety-net system connects pediatric patients and their families to resources, including food, housing and baby supplies, thanks to its partnership with Boston-based nonprofit Health Leads.

Pediatric clinic patients at Harlem Hospital, Bellevue Hospital Center and Woodhull Medical and Mental Health Center are screened for resource needs upon intake. A provider can “prescribe” basic resources like food and heat just as they do medication. Patients take those prescriptions to a Health Leads desk in the clinic waiting room, where the program’s trained college student “advocates” work side by side with patients to access community resources and public benefits.

“One of the most frequently requested [resources] is assistance with food,” Kansagra says. Health Leads staff can enroll eligible patients into the Women, Infants and Children’s program for food stamps, set families up with emergency food supplies or to food assistance programs or provide coupons to local farmers’ markets. More than 1,800 patients/families were connected in 2014 at the three hospitals. Now, HHC is expanding the program, Kansagra says, as “a large proportion of our patients do have needs.”

Health Leads works with 11 hospital and health systems, including Kaiser Permanente in California, Massachusetts General Hospital in Boston and The Johns Hopkins Hospital in Baltimore, to connect 50,000 patients and dependents with needed resources last year. “What this is really about is breaking down barriers,” says Kelly Hall, managing principal at Health Leads.

“Overall, Health Leads is contributing to the overall needs of patients,” Kansagra says. “The foods you eat or have access to to what your housing is like impacts health. Health is not only medical care. When patients are identifying needs and when we are helping them to meet those needs, we view that as a success.”

Meanwhile, the five-hospital Bon Secours Richmond Health System co-leads a partnership with Virginia Local Initiatives Support Corp. to revitalize Richmond’s East End. The effort, which makes grants to businesses to start or expand enterprises in the area, has attracted more than 20 businesses to date and is working to meet residents’ needs desires of “more affordable housing and job opportunities,” says David Belde, senior vice president of mission services at Bon Secours.

Working with nearly 50 nonprofits, Bon Secours is “co-creating a healthy community,” by focusing on economic development, Belde says. This includes stimulating and supporting local businesses, creating parks and working to attract a grocery store and a fitness and wellness center to the area. “People die too often and too young by diseases that are preventable. This results from poverty, lack of education” and other nonmedical care factors, Belde says. “Health care in the future needs to care for people who are sick and develop a strategy to keep people healthy.”