IMPROVING PATIENT CARE
Hospital-Based Violence Prevention: Progress and Opportunities
Jonathan Purtle, DrPH, MSc; John A. Rich, MD, MPH; Joel A. Fein, MD, MPH; Thea James, MD; and Theodore J. Corbin, MD, MPP
A substantial body of research shows that violently
injured patients are at high risk for violent reinjury,
violence perpetration, and symptoms of posttraumatic
stress (1, 2). The standard of care for assault injury,
however, does not reflect this knowledge—physical
wounds are treated and patients are discharged, often
to return with repeated injuries. Although many physi-
cians wish to act on this knowledge, as evidenced by a
recent call to action endorsed by 8 medical societies
(3), little concrete guidance on what they can do
is available. In this commentary, we describe how
hospital-based violence intervention programs (HVIPs)
work to translate research into practice. We discuss
challenges to HVIPs, steps that physicians can take to
overcome them, and opportunities for these programs
under the Patient Protection and Affordable Care Act
(ACA).
HVIP PRACTICE
The National Network of Hospital-based Violence
Intervention Programs comprises more than 25 HVIPs.
Broadly, these programs are all grounded in the theory
that hospital-treated violent injury is a “teachable mo-
ment” when patients are receptive to intervention. They
embrace a trauma-informed approach that views heal-
ing from psychological trauma as essential to effective
violence prevention. Although a detailed description of
HVIP logistics is beyond the scope of this commentary
and is provided elsewhere (4), we use our programs
(Philadelphia's Healing Hurt People, The Children's
Hospital of Philadelphia Violence Intervention Program,
and Boston's Violence Intervention Advocacy Program)
to illustrate how HVIPs work and highlight similarities
and differences between programs.
Our programs are similar across the domains of re-
cruitment, intervention components, and measures
of success. Violently injured patients are identified
through daily reviews of the emergency department's
medical record system and referrals from social work-
ers, nurses, or physicians. Program staff engage pa-
tients at the bedside (in the emergency department or
an inpatient room) and contact discharged patients by
phone. The initial encounter is focused on gaining pa-
tient trust, assessing short-term risk for reinjury and re-
taliation, and providing education about posttraumatic
stress symptoms. Plans are developed to address im-
mediate safety needs (such as arranging temporary
housing in a safe neighborhood), and an in-person ap-
pointment is scheduled to obtain the patient's consent
for participation.
Subsequent encounters focus on coordinating
follow-up medical care, managing symptoms of post-
traumatic stress, and resisting peer pressure to retali-
ate. A needs-and-assets evaluation is done across the
This article was published online first at www.annals.org on 25 August 2015.
IDEAS AND OPINIONS
domains of physical and mental health, education, em-
ployment, criminal justice, and family. After the assess-
ment, the patient and program staff mutually develop a
list of discrete goals (for example, applying to a job
training program, obtaining health insurance, and be-
ginning trauma-focused therapy). Program staff then
provide case management services—facilitating connec-
tions to community-based services, coordinating ap-
pointments, and providing transportation—to help pa-
tients achieve their goals. Encounters between the
patient and program staff take place in the community
and at program offices, with the frequency varying ac-
cording to patient needs. Progress is tracked through a
Web-based case management database, and the pro-
portion of goals achieved serves as a proximal measure
of program success. Patients typically participate in the
program for 6 months to 1 year.
Our programs differ in staffing structure. Licensed
social workers provide services to The Children's Hos-
pital of Philadelphia Violence Intervention Program;
Healing Hurt People's services are primarily provided
by licensed social workers but also by peer navigators
who have completed the program; and the Violence
Intervention Advocacy Program employs peer naviga-
tors recruited from local communities, who are paired
with licensed clinical therapists. All peer navigators
receive intensive training in program protocols and
trauma-informed practice. When licensed providers are
included, some program services (such as psychosocial
assessment) are reimbursable.
EVIDENCE ON HVIPS
Hospital-based violence intervention programs
have been studied in 5 randomized, controlled trials
and 2 quasi-experimental evaluations (4). Overall, re-
sults show substantial improvements in hospital read-
missions, arrests and convictions for violent crime, and
employment (4 – 6). Evidence of HVIP effectiveness is
strongest among the highest-risk patients. For exam-
ple, a randomized, controlled trial of patients with 2
prior hospitalizations for assault injury and histories of
probation and/or parole found that those involved in
an HVIP had significantly lower reinjury rates (5% vs.
36%) and conviction rates for violent crimes (13% vs.
55%) and higher employment rates (82% vs. 20%)
(7).
Three randomized, controlled trials; a quasi-
experimental multisite evaluation; and a Cochrane re-
view on HVIPs are in progress (8). Economic evalua-
tions suggest that these programs could produce
substantial cost savings for health care and criminal jus-
tice systems (6, 9). Qualitative research has begun to
elucidate HVIP mechanisms and the components most
valuable to patients (10). The strength of evidence on
© 2015 American College of Physicians 715
IDEAS AND OPINIONS
Table. Challenges and Strategies to Obtain HVIP Buy-In From Key Stakeholder Groups
Stakeholder Group Challenge
Violently injured patients Initial distrust of HVIP
Fear of police involvement
Desire to retaliate
Emergency department/trauma center Negative perceptions of violently injured patients
physicians, nurses, and staff (e.g., victims seen as perpetrators)
Skepticism of program effectiveness
Hospital administrators Competing budget priorities
HVIP = hospital-based violence intervention program.
HVIPs is limited, however, by small sample sizes, dispa-
rate outcome measures, variable follow-up periods,
and high attrition rates. To enhance the rigor of evalu-
ations, the National Network of Hospital-based Vio-
lence Intervention Programs has created a cross-site
data-sharing repository and is developing standardized
measures for outcome evaluations.
HVIP CHALLENGES, STRATEGIES, AND ACA
OPPORTUNITIES
In addition to the limited evidence base, HVIPs en-
counter challenges obtaining buy-in from key stake-
holders. The Table shows major challenges that we
have faced over the combined 25 years that our pro-
grams have been in operation and strategies to ad-
dress them.
Hospital-based violence intervention programs are
primarily funded through public, philanthropic, and
hospital grants and struggle to maintain financial sus-
tainability. The ACA, however, presents at least 3 op-
portunities to enhance program sustainability. First, it
resulted in a change to the Centers for Medicare &
Medicaid Services' regulation of preventive services.
Medicaid will now reimburse for preventive services
provided by nonlicensed providers if the services are
recommended by a physician. Although not specific to
HVIPs and subject to approval by the Centers for Medi-
care & Medicaid Services, this change could enable
programs to reimburse for more postinjury rehabilita-
tion services. Second, Medicaid expansions and subsi-
dies will expand health insurance to low-income pa-
tients involved in an HVIP. Improved coverage will
allow programs to receive reimbursement for covered
services for more patients. Finally, HVIPs help satisfy the
community benefit requirement for nonprofit hospitals,
which became more stringent under the ACA. Hospital
administrators have an incentive to support HVIPs to
maintain tax-exempt status.
716 Annals of Internal Medicine • Vol. 163 No. 9 • 3 November 2015
Hospital-Based Violence Prevention
Strategy
Describe HVIP as a “hospital service.”
Engage patients' families and friends.
Give brief presentations at meetings (e.g., faculty,
resident, and nurse) about violent injury epidemiology,
psychobiology of traumatic stress, and evidence of HVIP
effectiveness. Have a client co-present and discuss how
the program benefited them.
Develop allies through mutually beneficial partnerships
(e.g., show how HVIP data can be a source for research
projects and HVIPs can help satisfy trauma centers'
injury prevention activity requirements).
Quantify the financial burden of uncompensated care for
violent injury.
Alert media outlets about the HVIP to generate positive
press for the hospital.
Discuss the potential for reimbursement of HVIP services.
CONCLUSION
Physicians' commitment to addressing violence
is stronger than ever. Although more research is need-
ed about the effectiveness of HVIPs, they offer an
evidence-supported model that hospitals can adopt
to prevent violent reinjury, reduce health costs, and
modernize the standard of care for violently injured
patients.
From Drexel University School of Public Health, The Children's
Hospital of Philadelphia, Perelman School of Medicine at the
University of Pennsylvania, and Drexel University College of
Medicine, Philadelphia, Pennsylvania, and Boston University
School of Medicine, Boston, Massachusetts.
Grant Support: Drs. Purtle, Rich, and Corbin were supported
by the Philadelphia Department of Behavioral Health in Dis-
ability Services, the Stoneleigh Foundation, and The Annie E.
Casey Foundation. Dr. Fein was supported by the Violence
Prevention Initiative of The Children's Hospital of Philadel-
phia. Dr. James is supported by the Boston Medical Center,
the Boston Public Health Commission, the Massachusetts De-
partment of Public Heath, The Boston Foundation, and the
Robert Wood Johnson Foundation.
Disclosures: Authors have disclosed no conflicts of interest.
Forms can be viewed at www.acponline.org/authors/icmje
/ConflictOfInterestForms.do?msNum=M15-0586.
Requests for Single Reprints: Jonathan Purtle, DrPH, MSc,
Drexel University, Nesbitt Hall, 3rd Floor, 3215 Market Street,
Philadelphia, PA 19104; e-mail, jpp46@drexel.edu.
Current author addresses and author contributions are avail-
able at www.annals.org.
Ann Intern Med. 2015;163:715-717. doi:10.7326/M15-0586
References
1. Cunningham RM, Carter PM, Ranney M, Zimmerman MA, Blow
FC, Booth BM, et al. Violent reinjury and mortality among youth
www.annals.org
Hospital-Based Violence Prevention
seeking emergency department care for assault-related injury: a
2-year prospective cohort study. JAMA Pediatr. 2015;169:63-70.
[PMID: 25365147] doi:10.1001/jamapediatrics.2014.1900
2. Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan
MD, et al. Firearm-related hospitalization and risk for subsequent
violent injury, death, or crime perpetration: a cohort study. Ann In-
tern Med. 2015;162:492-500. [PMID: 25706337] doi:10.7326/M14
-2362
3. Weinberger SE, Hoyt DB, Lawrence HC 3rd, Levin S, Henley DE,
Alden ER, et al. Firearm-related injury and death in the United States:
a call to action from 8 health professional organizations and the
American Bar Association. Ann Intern Med. 2015;162:513-6. [PMID:
25706470] doi:10.7326/M15-0337
4. Purtle J, Corbin TJ, Rich LJ, Rich JA. Hospitals as a locus for vio-
lence intervention. In: Donnelly PD, Ward CL, eds. Oxford Textbook
of Violence Prevention: Epidemiology, Evidence, and Policy. Oxford,
UK: Oxford Univ Pr; 2014.
5. Snider C, Lee J. Youth violence secondary prevention initiatives in
emergency departments: a systematic review. CJEM. 2009;11:161-8.
[PMID: 19272218]
www.annals.org
IDEAS AND OPINIONS
6. Purtle J, Rich LJ, Bloom SL, Rich JA, Corbin TJ. Cost-benefit anal-
ysis simulation of a hospital-based violence intervention program.
Am J Prev Med. 2015;48:162-9. [PMID: 25442223] doi:10.1016/j
.amepre.2014.08.030
7. Cooper C, Eslinger DM, Stolley PD. Hospital-based violence
intervention programs work. J Trauma. 2006;61:534-7. [PMID:
16966983]
8. van der Westhuizen C, Sorsdahl K, Wyatt G, Williams J, Siegfried
N, Stein DJ. Psychosocial interventions in the emergency centre
setting for preventing reinjury due to interpersonal violence (proto-
col). Cochrane Database Syst Rev. 2013. doi:10.1002/14651858
.CD010839
9. Juillard C, Smith R, Anaya N, Garcia A, Kahn JG, Dicker RA. Saving
lives and saving money: hospital-based violence intervention is cost-
effective. J Trauma Acute Care Surg. 2015;78:252-7. [PMID:
25757108] doi:10.1097/TA.0000000000000527
10. James TL, Bibi S, Langlois BK, Dugan E, Mitchell PM. Boston
Violence Intervention Advocacy Program: a qualitative study of client
experiences and perceived effect. Acad Emerg Med. 2014;21:742-
51. [PMID: 25039818] doi:10.1111/acem.12409
Annals of Internal Medicine • Vol. 163 No. 9 • 3 November 2015 717
IMPROVING PATIENT CARE
Current Author Addresses: Dr. Purtle: Drexel University, Nes-
bitt Hall, 3rd Floor, 3215 Market Street, Philadelphia, PA
19104.
Drs. Rich and Corbin: Drexel University, 1505 Race Street, MS
1047, Philadelphia, PA 19102.
Dr. Fein: 3501 Civic Center Boulevard, Emergency Depart-
ment, CTRB, 9th Floor, Philadelphia, PA 19104.
Dr. James: Boston Medical Center, Department of Emergency
Medicine, Dowling 1 South, 818 Harrison Avenue, Boston, MA
02118.
www.annals.org
Author Contributions: Conception and design: J. Purtle, J.A.
Fein, T.J. Corbin.
Drafting of the article: J. Purtle, J.A. Rich, J.A. Fein, T. James,
T.J. Corbin.
Critical revision of the article for important intellectual con-
tent: J. Purtle, J.A. Rich, J.A. Fein, T.J. Corbin.
Final approval of the article: J. Purtle, J.A. Rich, J.A. Fein, T.
James, T.J. Corbin.
Collection and assembly of data: T.J. Corbin.
Annals of Internal Medicine • Vol. 163 No. 9 • 3 November 2015