From 2019 to 2020, homicides rose by 28 percent across the United States. In the same period, gun homicides rose by 35 percent, and gun-related deaths among Americans ages 19 and younger increased by nearly 30 percent. Gun violence is among the leading causes of death for youth in the United States. This violence disproportionately affects Black and Latino communities.
Community violence intervention (CVI) models are one way that communities are responding to gun violence. CVI programs “work to reduce homicides and shootings through trusted partnerships between community stakeholders, individuals most affected by gun violence, and government.” Some CVI models have led to as much as a 60 percent reduction in homicides.
Effective CVI efforts draw from a variety of methods, involve coordination across a whole community, and pull together multiple CVI programs to form community networks that comprehensively challenge violence.
Different CVI models engage with victims and perpetrators at distinct moments in the progression of violence. No single CVI model wholly addresses violence in a community; rather, employing these models in tandem leads to the best outcome. CVI models may range from community-driven crime prevention through environmental design, which addresses crime through architecture and urban planning, to the street outreach or violence interrupter model, which involves employing community representatives to directly mediate and break up violence as it is occurring. This column considers hospital violence intervention programs (HVIP), a CVI model in which experts and community members connect with victims in trauma centers and emergency rooms to help them begin the recovery process immediately.
Hospital-based violence intervention programs
Under HVIPs, trained providers meet with patients while they are in the hospital to begin building relationships with them, connecting them with wraparound services, and preventing them from retaliating against anyone who may have played a part in their injuries.
HVIPs were first developed in Oakland, California, in 1994, making them the oldest of all CVI programs. They are also the most researched CVI program. A 2004 evaluation of Oakland’s Youth ALIVE! program found that participants were 70 percent less likely to be arrested and 60 percent less likely to have criminal involvement than a control group. Additionally, the study revealed that the program saved hospitals up to $1.5 million annually.
This large sum is understandable considering that gunshot victims are typically uninsured, meaning that their hospital expenses—which can include costs for operation for their injury and trauma-informed follow-up care—are often covered by the hospital. Studies of other HVIPs, including San Francisco’s Wraparound Project and Baltimore’s Violence Intervention Program, have revealed similar successes in hospital savings and injury reduction.
Two components of the HVIP process
- Providing intervention during recovery: The process begins with the brief introduction of an intervention specialist at the bedside of an injured patient. As the patient recovers, the specialist begins guiding them and their family away from retaliation and revenge and providing services to address stress, emotional distress, and more. Interventionists are specially trained to build connections with patients in order to overcome historic distrust of the health care and criminal legal systems.
- Providing long-term care: The patient’s hospital stay is followed by continued care from the intervention specialist and other providers. Intervention specialists work to build connections with community-based resources to ensure that the patient experiences a seamless transition upon release. This may include connecting the patient to resources in job training, behavioral health, sexual assault recovery, or education. The intervention specialist then conducts mentoring, home visits, and long-term case management with the patient. They also look into the environment in which the patient lives, works, and spends time recreationally in order to better understand the patient’s case and assess whether they need to make broader lifestyle changes.
HVIP models across the United States
HVIP models across the nation have demonstrated successful results. This column highlights three: Oakland’s Youth ALIVE! program, the first HVIP established in the United States; San Francisco’s Wraparound project, which addresses the crisis of youth violence in the city; and the University of Maryland Medical Center’s Violence Intervention Program.
Oakland’s Youth ALIVE! Caught in the Crossfire program
In 1994, the violence prevention organization Youth ALIVE! developed Caught in the Crossfire, the nation’s first hospital-based intervention program. The program was inspired by the experiences and work of a young man named Sherman Spears, who was shot and paralyzed in 1989. While he was in the hospital, Spears felt overwhelmed: “His parents were distraught, his friends wanted revenge, and he didn’t feel like he could relate to the doctors and nurses.” But he ultimately chose not to retaliate. And after Spears connected with a violence-involved support group under Youth ALIVE!, “he began going to the hospital and meeting with other young victims of violence.” This work acted as a precursor to what has become the HVIP model. Beyond Caught in the Crossfire, Youth ALIVE! offers numerous prevention, intervention, and healing programs within other spheres of CVI.
Location: Oakland, California
Years active: 1994–present
Target population: Caught in the Crossfire works with violence-involved and hospitalized young people in Oakland. Many youths involved in the program have been shot, stabbed, or assaulted.
Method: The program seeks to aid participants through relationship-building with trained intervention specialists who offer long-term case management, connection to community services, home-based mentoring, and hospital-based assistance.
Outcomes: A 2004 evaluation of the program found that clients were 70 percent less likely to be arrested and 60 percent less likely to have criminal involvement than patients not engaged in the program. Additionally, it found that 98 percent of clients were not rehospitalized for violence-related injuries. A 2004 study that followed 112 violently injured Oakland youth found that Caught in the Crossfire led to between $750,000 and $1.5 million per year in hospital savings by reducing rehospitalization.
San Francisco’s Wraparound Project
The Wraparound Project operates out of San Francisco General Hospital with the understanding that health communication in the United States is “marred by cultural incompetence.” The program was founded in 2005 by Dr. Rochelle Dicker, a trauma surgeon who sought to stop the hospital’s revolving door of violently injured youth. The program aims to give patients alternatives to engaging in community violence by connecting them with higher education, mental health, and crime response services. Ruben Marquez, a senior case manager for the Wraparound Project, had this to say about why he got involved with the project: “I looked around and a lot of members of my community weren’t there. They were deceased, they were in jail, they were hooked on drugs. That was my teachable moment.”
Location: San Francisco
Years active: 2005–present
Target demographic: The Wraparound Project works with violently injured patients in San Francisco General Hospital who are ages 10 to 30 and susceptible to reinjury.
Method: After patients are stabilized, they are screened by case managers. Those who are considered to be at high risk for reinjury are invited to participate in the Wraparound Project, which provides patients intensive case management and guides them to risk reduction services.
Outcomes: In its first six years of operation, the project was associated with a 400 percent decrease in reinjury rates. Giffords Law Center’s analysis of the Wraparound Project found that prevention of just 3.5 injuries per year renders the program cost-neutral—and that at its current rate of prevention, the program saves hospitals around $500,000 per year.
Baltimore’s Violence Intervention Program
In 1998, Dr. Carnell Cooper began Baltimore’s Violence Intervention Program at the University of Maryland Medical Center. He launched the program after seeing violently injured patients continuously reinjured and readmitted to the hospital. The program is particularly vital in Baltimore, which has the nation’s second-highest gun-related death rate. It operates on the underlying belief that trauma patients are undergoing a psychological crisis and focuses on four basic phases: stabilization, recovery, community reintegration, and self-reliance.
Years active: 1998–present
Target demographic: Baltimore’s Violence Intervention Program works with any University of Maryland Medical Center patient admitted due to violent injury and at risk of reinjury.
Method: Once patients agree to participate in the HVIP, they are paired with a case manager or outreach worker. These individuals help patients to form an individualized plan to combat risk factors associated with reinjury.
Outcomes: A 2006 evaluation of the program revealed that only 5 percent of participating patients who received intervention treatment were rehospitalized, compared with 36 percent of nonparticipants. This rehospitalization reduction led to estimated health care savings of nearly $600,000. Additionally, patients who participated in the program were half as likely to be convicted of a crime as nonparticipants, as well as four times less likely to be convicted of a violent crime. This saved the state approximately $1.25 million in incarceration costs.
The Healthy Alliance for Violence Prevention
Within the sphere of HVIP, The Health Alliance for Violence Intervention (HAVI) is a significant player. HAVI fosters communication and collaboration among hospitals; encourages equitable, trauma-informed care; and supports violence intervention and prevention programs. It currently oversees 34 member programs across the United States and in three other countries, more than 350 practitioners, and dozens of budding programs. Oakland’s Caught in the Crossfire program and San Francisco’s Wraparound Project are both member programs of HAVI.
The HVIP model needs more research, funding, and coordination
Wider research is necessary to grow the HVIP model and increase patient participation. Many hospitals have run small-scale trials that have measured positive outcomes; however, large-scale control trials are difficult to carry out in HVIP programs, as those experiencing trauma are often hesitant to participate in studies.
Increased funding is needed to expand HVIPs. Medicaid reimbursement offers a promising means of funding continued growth. In June 2021, the governors of Connecticut and Illinois signed bills that direct their states’ Medicaid agencies to cover beneficiaries’ HVIP costs. The Biden administration also informed state leaders in April 2021 that Medicaid “could cover evidence-based violence prevention programs.”
Indeed, as Giffords writes, “No singular CVI approach is going to eliminate community violence; rather, the success of a CVI strategy is only as strong as its coordinated community networks.” An effective CVI approach pairs multiple programs together to address communities’ unique environmental, social, and health care needs.
Addressing violent crime requires engaging community members in dismantling systems intertwined with poverty, racism, and generational violence. HVIPs help address these issues by employing specialists to work directly with victims of violence during their recovery process. The model helps individuals rebuild their lives and strengthen their communities. With increased funding and attention, hospital-based violence intervention programs can continue transforming communities from the inside out.