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Service Delivery Innovation Profile

Hospital-Based Program Educates and Arranges Community-Based Support for Young Victims of Violence, Leading to Fewer Repeat Episodes


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Snapshot

Summary

Under the Rochester Youth Violence Partnership, University of Rochester Medical Center staff work in collaboration with community partners to provide various services to young victims (under age 18) of penetrating trauma, with the goal of changing behaviors and preventing repeat occurrences. In addition to providing traditional medical treatment, emergency department and hospital staff assess the patient’s psychosocial risk factors and connect high-risk youth to community services (e.g., counseling, substance abuse treatment, case management) that can help reduce those risks. Staff also use educational tools to highlight the risks and consequences of youth violence, leveraging the visit as a "teachable moment" during which youth and families may be motivated to change future behaviors. The program appears to have improved the behaviors of victims of violence and reduced the incidence of repeat penetrating trauma injuries.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation reports from patients and family members served by the program, along with the number of repeat visits for violent injuries by those 18 and under who previously received program services.
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Developing Organizations

University of Rochester Medical Center
The Rochester Youth Violence Partnership involves 33 community partners, including (but not limited to) Pathways to Peace, Rochester Police Department, Project Exile, Monroe County Child Protective Services, Monroe County Probation, New York State Division of Criminal Justice Services, Monroe County District Attorney’s Office, Action for a Better Community, and Partners Against Violence Everywhere.end do

Use By Other Organizations

As noted, a similar program operates out of the district attorney's office in Buffalo, NY.

Date First Implemented

2006
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Patient Population

Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Urban populationsend pp

Problem Addressed

Victims of penetrating trauma, particularly children and adolescents in urban areas, face a high risk of future assault and death. Hospital emergency departments (EDs) and inpatient units represent an underutilized but potentially effective venue for identifying and supporting at-risk youth, as staff can leverage the time in the hospital as a "teachable moment" for youth and family.
  • Increased risk of repeat assaults: An analysis of 501 urban trauma patients found that, over 5 years, 148 (roughly 30 percent of the total) experienced a second trauma event and another 115 (23 percent) experienced multiple recurrent events, with 20 percent of these repeat victims dying.1 A separate study found that patients with an initial penetrating trauma injury are likely to return to the ED with penetrating injuries a second and third time, with mortality risk increasing with each incident.2 Some experts consider urban trauma to be a "chronic recurrent disease."
  • Especially for youth: Homicide represents the second leading cause of death for children and youth ages 10 to 24, with 84 percent being due to gun-related violence.3 Young urban victims of assault face an increased risk of subsequent attacks because most urban youth victims know their attackers. A survey found that 70 percent of young victims knew or knew of their assailants, with 56 percent of injuries relating to a past disagreement. Of these cases, 29 percent of victims had been previously threatened by—and 16 percent had previously fought with—their assailant.4 Other studies confirm that urban youth are at high risk of interpersonal violence, including one or more episodes of penetrating trauma.5,6
  • Unrealized potential of hospitals to intervene: ED and hospital staff have a unique opportunity to identify and support young victims of violence. In 2008, more than 656,000 young victims of violent episodes received treatment in an ED.3 The provision of medical treatment in the ED and during a subsequent inpatient admission represent "teachable moments" for youth engaged in risky behaviors, yet relatively few hospitals use these visits as an opportunity to identify and support those at risk of repeat violent episodes.

What They Did

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Description of the Innovative Activity

The University of Rochester Medical Center works in collaboration with community-based partners to provide various services to young victims of penetrating trauma who come to the ED, with the goal of changing behaviors and preventing repeat occurrences. Along with traditional medical treatment, staff assess the patient’s psychosocial risk factors and connect high-risk individuals to community services that can help reduce those risks. Staff also use educational tools to highlight the risks and consequences of youth violence, leveraging the ED visit and subsequent inpatient stay as "teachable moments" during which youth and families may be motivated to change behaviors. Key program elements include the following:
  • Identification of at-risk youth: The program serves any youth under age 18 who has been shot or stabbed. Typically, when a child or adolescent victim of a penetrating injury arrives at the ED with police or emergency medical services, the Rochester Police Department notifies Pathways to Peace, a community outreach program that channels at-risk youth to community resources that can help them. A Pathways to Peace outreach worker (if possible someone familiar with the victim) comes to the ED to provide support.
  • Psychosocial assessment following medical care: Injured youth receive traditional medical care by ED clinicians and trauma surgeons, who also notify the hospital's pediatric social worker of the need for a psychosocial assessment. At the appropriate time (given the needed medical care), the social worker conducts a psychosocial assessment using an internally developed form. The assessment identifies risk factors for future violence and helps the social worker determine how best to ensure the patient's safety after discharge. Topics covered include a review of family history and past criminal charges (including probation), mental health issues, and substance use. The assessment also helps patients identify factors in their lives that they might want to change to reduce the risk of future harm.
  • Hospital admission if needed: The patient is admitted to the hospital if warranted by his/her injuries or if the social worker determines that he/she cannot be safety discharged due to psychosocial risk factors. Clinicians consider psychosocial risk factors when determining medical necessity for admission and continued hospital stay, as they want to ensure these risk factors are addressed and patients can be safely discharged.
  • Additional psychiatric assessment for those hospitalized: A pediatric psychiatrist evaluates all hospitalized youth trauma patients. The psychiatrist assesses the patient's future risk of injury, provides counseling, and attempts to increase the patient’s motivation to make lifestyle changes to reduce future risk.
  • Education during "teachable moments": ED and inpatient clinicians view treatment for a violence-related injury as teachable moments when it may be possible to engage youth and families in an understanding of their risky behaviors and encourage them to make changes to reduce this risk. Thus, once patients have been stabilized, the hospital uses two educational tools to highlight the risks and consequences of youth violence and to encourage patients to change. These tools include:
    • "Voices of Violence" video: This video includes interviews with adolescent victims of violence and parents of young murder victims. Following the viewing, the social worker holds a debriefing session with the patient and family members to discuss their response to the content, how the incident causing the injury could have been avoided, and how to avoid future incidents.
    • Document of Understanding: After watching the video, patients and families receive a "Document of Understanding," which reflects the content presented in the video. The document outlines the risks associated with exposure to violence, notes that hospital staff believes that the patient remains at high risk of future injury or death, and offers the patient the opportunity to work with hospital staff to reduce this risk. The social worker asks the patient and the parent/guardian to sign the form, indicating that they have been informed of the future risk of injury and that the parent/guardian acknowledges responsibility for the child's future safety.
  • Referral to appropriate community resources: The social worker and the Pathways to Peace outreach worker identify appropriate community partners who can address targeted risk factors. Upon discharge from the ED or inpatient unit, they refer patients for interventions such as counseling, substance abuse treatment, school interventions, gang interventions, child protective services, or case management services for at-risk youth.

Context of the Innovation

The University of Rochester Medical Center includes Strong Memorial Hospital (a 739-bed academic medical center), Highland Hospital, and Golisano Children's Hospital. Strong Memorial Hospital and Highland Hospital handle approximately 60,000 patient discharges and 130,000 ED visits each year. Strong Memorial operates the only Level One trauma center in the region, caring for roughly 1,700 trauma patients annually, including 75 to 100 youth with penetrating trauma injuries. Dr. Mark Gestring, a trauma surgeon, and Jeff Rideout, a pediatric social worker, decided to launch the program after repeatedly seeing young victims of penetrating trauma return to the ED with subsequent injuries. They decided to create a way for hospital-based clinicians and community partners to work together to reduce this cycle of violence.

Did It Work?

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Results

The program appears to have changed the behaviors of victims of violence and reduced the incidence of repeat penetrating trauma injuries.
  • Anecdotal reports of behavior change: Reports from those served by the program suggest it has made a meaningful difference in their lives, encouraging them to change their behaviors to reduce the risk of violence in the future. For example, one parent reported that the video dissuaded her from retaliating against her son’s attacker. A second victim reported that, after a long recuperation period during which he received counseling and other services, he stopped engaging in many risky behaviors and began taking classes at a community college.
  • Apparently leading to reduced recidivism: Program developers believe that the initiative has reduced the recidivism rate among those served. In 2007, nine youth victims previously treated in the ED returned as a result of subsequent violence. Since that time, no youth who participated in the program has returned to the hospital. That said, these data may not tell the whole story because tracking repeat episodes can be difficult. For example, the program serves those 18 and under and does not track return visits from former participants over that age. In addition, the at-risk youth population can be transient, meaning that program developers do not know if those served experienced a subsequent violent injury in a different jurisdiction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation reports from patients and family members served by the program, along with the number of repeat visits for violent injuries by those 18 and under who previously received program services.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Forming hospital-based multidisciplinary group: Dr. Gestring and Mr. Rideout formed a workgroup that included representatives from various hospital services and departments, including the ED, trauma surgery, pediatric surgery, pediatrics, adolescent medicine, psychiatry, nursing, social work, and security.
  • Creating assessment form and educational tools: The workgroup created the Psychosocial Assessment Form, the Document of Understanding, and the "Voices of Violence" video (produced in collaboration with Rochester Community Television).
  • Outreach to community organizations: Workgroup members reached out to various community-based and government organizations with a mission related to reducing youth violence. They made presentations at board meetings and/or to organizational leaders and staff to solicit interest in participating. During this process, they learned of additional organizations with a similar mission and subsequently contacted their leaders as well. Several representatives from interested organizations joined the workgroup.
  • Designing communication processes: The expanded workgroup outlined the communication and referral processes for partner organizations to ensure that youth obtained needed services after discharge. This process included designating a point person at each organization to be available 24 hours a day to handle case-specific issues.
  • Ongoing monthly partner meetings: Representatives from the various partner organizations meet monthly to discuss joint activities, organization-specific programs, and potential new strategies for working together to improve the safety of at-risk youth. The meeting also serves to highlight the aforementioned point person at each organization to be contacted when case-specific issues arise.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff at the hospital and partner organizations integrate activities into their routine responsibilities.
  • Costs: Data on program costs are not available.
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Funding Sources

The partnership does not have a budget; partner organizations fund their involvement in program-related initiatives and activities.end fs

Tools and Other Resources

Potential adopters can request the Psychosocial Assessment Form and the Document of Understanding by contacting the innovators.

Adoption Considerations

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Getting Started with This Innovation

  • Create program based on community needs and resources: Identify all community organizations that serve at-risk youth, solicit their interest in participating, and be flexible in structuring the program based on community needs and resources. For example, a similar program in Buffalo, NY, operates out of the district attorney's office rather than a hospital.
  • Leverage existing resources: This type of initiative can be developed without significant funding. Most urban areas have many community programs in place that target at-risk youth. This program focuses on using these resources more effectively by improving coordination of services and avoiding duplicative efforts.
  • Share control: Although some organizations may take a leadership role in implementing a particular program or activity, the partnership should be equal and collaborative. For example, the hospital spearheaded development of the Rochester Youth Violence Partnership, but all partners retain an equal voice in decisionmaking, generation of new ideas, and speaking on behalf of the program.

Sustaining This Innovation

  • Be persistent in soliciting new partners: Convincing new partners to join can sometimes be difficult. Rochester Youth Violence Partnership members have found that "respectful persistence" can be effective, with an emphasis on how the program can be a mutually beneficial endeavor. To the extent possible, existing partners should accept all invitations to speak about the program and collaborate with other organizations. This approach has helped in adding new partners over time.
  • Continue to evolve: Partners should meet regularly to discuss operations and solicit ideas for improving program services.

Use By Other Organizations

As noted, a similar program operates out of the district attorney's office in Buffalo, NY.

More Information

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Contact the Innovator

Michael Scharf, MD
Assistant Professor of Psychiatry and Pediatrics
University of Rochester Medical Center
601 Elmwood Ave
Rochester NY 14642
(585) 275-3556
E-mail: michael_scharf@urmc.rochester.edu  

Mark Gestring, MD FACS
Medical Director, Kessler Regional Trauma Center
Associate Professor of Surgery, Emergency Medicine and Pediatrics
University of Rochester Medical Center
601 Elmwood Ave
Rochester NY 14642
(585) 275-0703
E-mail: mark_gestring@urmc.rochester.edu  

Jeff Rideout, MSW
Pediatric Social Worker
University of Rochester Medical Center
601 Elmwood Ave
Rochester NY 14642
(585) 275-7487
E-mail: jeff_rideout@urmc.rochester.edu

Innovator Disclosures

Dr. Scharf, Dr. Gestring, and Mr. Rideout have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

University of Rochester Medical Center Web site. State Organization Honors Medical Center Anti-Violence Program. June 24, 2010. Available at: http://www.urmc.rochester.edu/news/story/index.cfm?id=2902

Footnotes

1 Sims DW, Bivins BA, Obeid FN, et al. Urban trauma: a chronic recurrent disease. J Trauma. 1989;29(7):940-6; discussion 946-7. [PubMed]
2 Brooke BS, Efron DT, Chang DC, et al. Patterns and outcomes among penetrating trauma recidivists: it only gets worse. J Trauma. 2006;61(1):16-9; discussion 20. [PubMed]
3 U.S. Centers for Disease Control and Prevention. Youth Violence: Facts at a Glance 2010. Available at: http://www.ncjrs.gov/yviolence/statistics.html
4 Cheng TL, Johnson S, Wright JL, et al. Assault-injured adolescents presenting to the emergency department: causes and circumstances. Acad Emerg Med. 2006;13(6):610-6. [PubMed]
5 Dowd MD. Consequences of violence. Premature death, violence recidivism, and violent criminality. Pediatr Clin North Am. 1998;45(2):333-40. [PubMed]
6 Redeker NS, Smeltzer SC, Kirkpatrick J, et al. Risk factors of adolescent and young adult trauma victims. Am J Crit Care. 1995:4(5):370-8. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 11, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 20, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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