Patients who are victims of violence (VOVs) are offered life-saving medical care and follow up. VOVs are not offered violence prevention services that address the risk factors during this critical time in order to prevent “recurrence,” or repeat episodes of violence. The advent of HVIPs has shown the success of a “teachable” moment that occurs following a traumatic event, in which individuals are more receptive to intervention immediately following an injury. It is thought that during efforts in primary prevention, individuals may not have the context to see themselves as high risk or to understand their social determinants profile, but once injured, people are receptive to tangible opportunities to change their risk profile. This is the “teachable moment.” Other disciplines in medicine have precedent in utilizing this “teachable moment” prior to HVIPs. For example, in the field of Cardiology, a patient experiencing a myocardial infarction demonstrates more capacity to accept changes in diet, exercise, and blood pressure control than prior to the event.
During this crucial time, VOVs may be receptive to the idea that they can change their social determinants profile, but there is little evidence that physicians are the most effective messengers . Much more evidence supports intervention specialist (IS) who are relatable individuals from the community as essential credible messengers for prevention following trauma . Through a relationship-based mentoring and case management model, the IS engage at-risk VOVs while they are hospitalized, and provide them with individualized support. This relationship then continues for a variable period of time, but is typically long term, and can last for years from the time of program enrollment. The ISs continue through this period with intensive contact, mentoring, and case management and are willing to be a highly available, reliable contact to victims of violence. ISs initial actions as mentors include the following: Connect and assist with immediate safety planning, enroll and refer clients to existing community resources serving victims of crime, assist in application for victim of crime compensation funding and provide referral to legal assistance for this application, and connect individuals to victim advocates. The bulk of the work is done post-discharge with the VOV and is based upon an evolving needs assessment.
It is essential that ISs are culturally competent to the communities in which they work, which often requires that they reside in the community and have a working understanding of the key community and cultural factors at play in that environment. These individuals should also have a working knowledge of the resources that are available to victims of violence, and typically continue to develop this knowledge base through their employment in the HVIP. It is recommended that the hiring of these individuals is done with the assistance of a community advisory board or community leaders who can identify individuals who have a working knowledge of the community dynamics.
Key to the HVIP model is the recognition, in a public health model, that risk of violence is rooted in modifiable risk factors that often represent social determinants of health, and that mitigating these risk factors, could reduce future risk for violent re-injury and improve overall well-being. The case management that occurs within the HVIP is focused on addressing social determinants of health through a community-based approach. Examples of appropriate services include assistance with meeting education goals, employment and job training assistance, housing assistance, and the attainment of mental health services. ISs often help process necessary paperwork for patients, such as victims of crime compensation paperwork, or paperwork to help patients obtain government identification. Depending on the needs of the patient, ISs may also help the individual navigate the utilization of other community resources, such as substance abuse clinics, health insurance applications, housing applications, applications for state and federal assistance, or the attainment of services and charity-based donations from faith-based organizations.
Often, HVIPs will employ a coordinator or social worker skilled at developing relationships with service providers, potential employers for VOVs, and community-based organizations. This individual may also serve as a reference for complex cases when the scope of case management falls beyond the capacity of a single individual or the scope of the ISs proficiencies.
In order to understand the flow of how victims of violence are approached, enrolled, and taken through HVIP services, the following is a step-by step guide [12••].
A victim of violence is seen at the Trauma Center and resuscitated as per standard protocol
If an intervention specialist is on site during this time, he or she typically makes contact with family or other next of kin. They may help diffuse anger and frustration over the event, but this is not the main goal of these ISs. Some cities have concomitant violence interrupter programs such as Cure Violence that provides this important service.
Once stabilized, the IS will go to the bedside of the injured victim and begin to establish rapport.
This process may be slow and require several bedside visits. If the patient is discharged, this relationship development may take place outside of the hospital.
Once rapport is established, the victim is offered enrollment into the HVIP. If the victim accepts, consent is obtained (maintaining a database is critical) and a needs assessment begins to develop.
A needs assessment is often dynamic and based upon the victim’s mental and physical state.
Needs include but are not limited to mental health services, job training, employment, education, tattoo removal, substance abuse treatment, housing, victim of crime assistance, and court advocacy.
Mental health care is frequently the priority need in this population. They have often been retraumatized (see below for more detail) and a Trauma Informed Approach is essential .
The victim is discharged from the trauma center and the IS continues to maintain a close relationship, shepherding the victim through risk reduction resources in the city or community based on the needs assessment.
This process may take months to years but the most intensive period is typically the first 6 months.
There are many HVIPs that offer in-house services such as resume development or life skills training.
Sometimes the ISs will simply meet their clients for a meal, just to maintain that special mentoring relationship.
Although clients at times “graduate” from the program, the door is never closed to them.
Needs assessments performed by ISs on victims of violence have revealed a great requirement for mental health services. The presence of symptoms associated with PTSD, anxiety, depression, and acute stress response (many of which are preexisting conditions) often render a victim of violence unready to seek stable employment. This makes addressing mental health a priority in our population. Traditionally, our young, injured population has been reluctant to seek out mental health services, but with the facilitation by a IS, this has become possible and acceptable to our population. Once mental health challenges are in the process of being addressed, it is much more likely that a VOV will succeed in other areas such as employment.
Initial reported data from HVIPs has been promising. This data has compelled the national adaptation of this model to programs throughout the USA and internationally. Additionally, in 2009, the National Network of Hospital Based Violence Intervention Programs was formed. This group served to bring together programs to provide technical assistance, best practice guidelines, policy advocacy, data sharing, and support through an organization and an annual conference. In 2019, this group was renamed the Health Alliance for Violence Intervention (HAVI), to reflect the contribution of programs that are community based, hospital linked (in contrast to hospital based), and based out of departments of public health. While these programs vary in their implementation strategies, funding streams, and overseeing bodies, they are uniform in their commitment to the public health approach to violence reduction.