Interpersonal violence is a major public health problem in the United States. Hospitals stand on the front lines of the epidemic.

Homicide is the leading cause of death among African Americans ages 15-34, second among Hispanics of this age group, and fifth among whites. Homicide was responsible for 19,362 deaths in 2016, translating to more than 607,886 potential life years lost and more than $25 billion in medical costs and lost productivity, according to the Centers for Disease Control and Prevention (CDC). Although the social and economic costs of homicide are significant, nonfatal violent injuries outnumber fatal by more than one hundred-to-one. In 2015, hospitals treated an estimated 1.5 million incidents of nonsexual violent assault across the country. The average cost of medical care for an incident of non-fatal violent injury that requires hospitalization is approximately $29,201. Incidents that do not require hospitalization on average cost about $2,646. These figures do not account for justice-system-related costs associated with violence or social costs to injured people, their families, and communities. 

The HAVI defines interpersonal violence as "the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation," consistent with the definition used by the World Health Organization. Interpersonal violence disproportionately impacts men and young people, and is a driver of racial and ethnic health disparities in the United States. In 2015, hospitals treated approximately 196,959 incidents of violence committed against African American males ages 15-34, not including fatal injuries.

Because violent victimization is typically not a one-time event, some health organizations consider it a “recurrent disease.” Unfortunately, hospitals typically treat and release those with violent injuries, caring for their physical wounds but providing little that will prevent violence in the future. In urban settings, studies estimate that up to 41 percent of patients treated for violent injury are re-injured within five years. One survey of victims of violence at five-year follow-up found that 20 percent of patients treated for violent injury had died. This “revolving door” phenomenon is well-documented in the medical literature and a recent systematic review of 19 studies on violent reinjury rates has confirmed its prevalence.

Being the victim of violence also significantly increases a person’s likelihood of engaging in violent behaviors against others, often as retaliation for the initial injury. Research suggests that the “code of the street,” a set of cultural norms that structures social life in many inner-city neighborhoods, may lead violently-injured youth to believe that they must retaliate against their perpetrator in order to avoid revictimization. Opportunities for economic self-sufficiency are also limited in low-income communities plagued by violence, leading some to seek opportunities in the drug trade or other illicit markets—further increasing their risk of violent injury.

In the absence of intervention programs, hospitals typically discharge violently injured patients to the same environment where they were injured, without a viable strategy for how to stay safe, manage peer pressure to seek revenge, and change their life for the better.

In addition to the physical consequences, many violently-injured people experience post-traumatic stress disorder (PTSD), depression, and substance abuse disorders that persist long after their wounds have healed. Symptoms of PTSD include internal fear, hypervigilance, estrangement from others, and emotional detachment. Surveys in urban areas have found that between 15 and 23 percent of victims of violence meet criteria for PTSD, and surveys in hospital settings have shown similar results. A study of clients participating in a Philadelphia-based HVIP found that 75 percent met the criteria for PTSD at six weeks follow-up.

Despite the psychological trauma of violent injury, many victims of violence do not receive mental health services. Barriers to services include perceived stigma of mental illness, distrust of mental health professionals, lack of knowledge about where and how to secure care, the cost of care, and difficulties obtaining crime victim compensation to cover the cost of mental health treatment. This is troubling because the psychological trauma of violent injury can lead people to obtain weapons or engage in substance use, increasing their risk of reinjury and retaliation, and thus rehospitalization and incarceration.

The mental health consequences of violent injury may also be compounded by the effects of traumatic experiences earlier in life. People with histories of trauma stand greater risk for developing PTSD after a violent assault than those who do not. A study on adverse childhood experiences (ACEs) revealed that early traumatic experiences significantly increase the risk of engaging in violent behavior and/or violent victimization, as well as a range of adverse behaviors and health outcomes. Many victims of violence live in neighborhoods where community violence, household dysfunction, and exposure to trauma are prevalent. For example, the Philadelphia study mentioned earlier found that 50 percent of HVIP clients had four or more ACEs, increasing their risk for injury-related PTSD and many other negative physical and mental health outcomes.

While many strategies exist to break cycles of violence, hospitals present a unique opportunity to reach high-risk populations at a moment when they are particularly responsive to intervention. By following the collaborative care approach, HVIPs can create change in a traumatized victim.

Hospital-based violence intervention programs (HVIPs) combine the efforts of medical staff with trusted community-based partners to provide safety planning, services, and trauma-informed care to violently injured people in hospital settings. In the mid-1990s, two organizations—Youth ALIVE! In Oakland, California and Project Ujima in Milwaukee, Wisconsin—developed the nation’s first HVIPs. While these nonprofit organizations were developing the HVIP model in direct response to a pressing community need, professional organizations in the healthcare sector, like the American Academy of Pediatrics, and government entities in the criminal-justice sector, like the Department of Justice’s Office for Victims of Crime, began to acknowledge the importance of violence prevention in hospitals. HVIPs continued to proliferate across the country in the late 1990s and early 2000s and reached a critical mass in 2009 when Youth ALIVE! hosted the first national symposium for HVIPs. With support from Kaiser Permanente, the symposium brought together over 30 representatives from HVIPs, and the HAVI (then known as the National Network of Hospital-based Violence Intervention Programs) was born. To date, there are over 30 member programs across the U.S. and in 3 other countries, dozens of emerging programs, and a community of over 350 practitioners, researchers, and policymakers who meet annually.

The practice of HVIPs relies on the “teachable moment,” the rare opportunity during which people are particularly receptive to interventions that promote positive behavior change, that a violently injured victim experiences in the hospital. Several studies have demonstrated the effectiveness of interventions at these moments in healthcare settings. HVIPs reach people caught in cycles of violence immediately after they have been injured. At this teachable moment, violently injured people stand at a crossroads: they can continue on their prior path and seek retaliation for the violence they suffered, or they can turn their traumatic experience into a reason to exit “the game” and alter their life trajectory. 

Programs employ violence prevention professionals to harness the power of the teachable moment. These highly trained paraprofessionals, who often come from the community in which they are working, can quickly gain trust and engage violently injured patients and their families in the emergency department, at the hospital bedside, or soon after discharge. They provide brief crisis intervention, links to community-based services, mentoring, home visits, follow-up assistance, and long-term case management. Different communities use different titles—like “intervention specialists,” “hospital responders,” “peer specialists,” “prevention professionals,” or “community health workers”—but all of them fit under the definition of violence prevention professionals in the National Uniform Claims Committee’s health provider taxonomy. Their goal is to prevent reinjury and retaliation, while promoting recovery from the trauma of violent injury. 

Many high-risk people who have suffered violent injuries are extremely distrustful of mainstream institutions like the healthcare and criminal-justice systems, which have often failed them in the past, and they may be resistant to intervention from these sources. Using a trauma-informed approach, violence prevention professionals can often break through this distrust. Their people skills, “street cred,” cultural sensitivity, and shared histories of exposure to trauma allow them to connect with high-risk people and address their wants and needs. After gaining trust and introducing the program, violence prevention professionals work with clients and their families to develop a plan for after their discharge from the hospital that meets their immediate safety needs, provides services, and establishes goals. This form of intensive case management promotes survivors’ physical and mental recovery while also improving their social and economic conditions. 

Recent research demonstrates that victims of violent injury require a variety of services beyond traditional medical care. In a ten-year review of the San Francisco Wraparound Project, an HVIP based at the University of California, San Francisco, researchers found that patients’ self-reported a variety of needs, most commonly including culturally-appropriate mental healthcare (51 percent), victims-of-crime assistance (48 percent), employment (36 percent), housing (30 percent), and education (28 percent). In order to provide these services, violence prevention professionals assist patients in getting follow-up medical care, mental health and substance abuse treatment, emotional support, education support, job training, and housing assistance. They often conduct home visits and transport clients to appointments.

HVIPs embrace a trauma-informed approach that recognizes that survivors of violence need both their psychological and physical wounds addressed in order to fully heal and recover. In addition to providing clients with education about the symptoms of post-traumatic stress and connecting them with mental health services, HVIPs’ practices are informed by an understanding that many violently injured people have extensive histories of trauma that affect their psychological, social, and biological wellbeing. Violence intervention professionals rely on this understanding, which improves outcomes for their clients.

Exposure to extreme and chronic stress substantially increases risk for adverse health outcomes—such as heart disease, diabetes, obesity, substance abuse, depression, and sexually transmitted diseases, a fact acknowledged by the Centers for Disease Prevention and Control and the American Academy of Pediatrics, and demonstrated in a growing body of literature that includes the ACE Study. By assessing clients for histories of trauma connecting them with treatment, HVIPs may help prevent a range of health conditions. 

The programs provide a unique opportunity to reduce disparities in the healthcare system for victims of violence, who are often uninsured and otherwise isolated from the healthcare systems.