We commend Wical et al for their detailed exploration of the experiences of hospital-based violence intervention program (HVIP) participants, as well as their families and program staff.1 Their findings highlight not only the limitations of the programs they studied, but also the potential and importance of the HVIP model.
Many patients have needs that exceed what the conventional healthcare system can offer, but it is abundantly clear that survivors of violent injury are a particularly high-need and vulnerable group with needs that far exceed these limits. Violence is a highly structurally analyzed disease process whose impacts are concentrated in communities and neighborhoods affected by structural racism, disenfranchisement, and disinvestment.2 The experience of surviving a violent injury only adds to the challenges that patients face: physically, mentally, emotionally, socially, and economically.3 Framing the goal of HVIPs primarily as entities designed to prevent recurrent violent injury fails to capture the complexity of how these programs have evolved and continue to evolve.4 HVIPs are designed to support patients and to serve as a bridge between medical care and community services, providing individualized services to support individual strengths and meet individual needs.
We agree with the authors and their participants that primary prevention is essential, that individuals need and deserve both individual support and systematic change long before they are shot. At the same time, as clinicians, we care for those affected and find them no less deserving of care and resources. We want to raise up the authors’ point that the focus on individual level-change can be “easily co-opted to unduly blame individuals for the structural causes which impinge on their ability to meet their daily needs.” Rather than seeing the postinjury healthcare encounter as a “teachable moment” aimed at individual behavioral change, we see the moment of contact with the health system as an opportunity not only for the patient, but for us, the healthcare team and the HVIP team to do more than what has conventionally been seen as our responsibility.
This article highlights a major gap in the field. Despite the efforts of the Health Alliance For Violence Intervention—the national convening and training body for HVIPs—to develop standards and indicators for HVIPs,5 there is no standardized approach to this care. HVIP programming ranges from the bare minimum to very extensive services, with little understanding of how this variation affects patient experience or outcomes.
Wical et al talk clearly about how HVIP services vary: the programs studied had to curtail services due to funding. This is common, and consequential, not only to the patients who may or may not receive specific services, but also because as programs expand and contract due to variable funding, expertise and commitment to the field are much more difficult to develop. The frustration that participants, families, and particularly program staff express is palpable in this article. We do not claim that the frustration inherent in caring for patients within dysfunctional or violent systems can ever be eliminated, but the more resources programs can provide, the more needs we can address, and the more we decrease the moral injury that comes from providing care that feels inadequate.
In their commentary Vogel and Kaser emphasize the limits of HVIPs within a society that perpetuates community violence.6 We agree, but we also think that the trust formed between a patient, family, and HVIP soon after injury is valuable and fragile, and we aim to make the most out of the opportunities we have. Although we agree with Wical et al as well as Vogel and Kaser, that close partnerships with communities and community organizations are essential, this is not an easy solution. Community organizations, too, have limited availability and are subject to the same inconsistent funding, understaffing, and variability in programming faced by many HVIPs. The burden falls on HVIPs to find and vet community partners to avoid broken promises or unmet needs for survivors.
Through our program in Philadelphia we have been fortunate to expand and maintain services that include not only the basics of psychosocial support and case management but also transportation, financial assistance, direct access to high-quality mental healthcare through built-in program therapists, and housing assistance. None of these services exist in a vacuum: all rely on close collaboration with community organizations and partners within and beyond the health system. As for the participants interviewed here, housing is of particular concern to our participants who may have been marginally housed before injury and now seek relocation for safety after injury. We collaborate closely with city agencies and local non-profits to establish safe relocation for many program participants.
Our program has been lucky to expand our services with the support of not only state, city, and private grant funding but most recently, and perhaps most importantly, with the commitment of our health system to sustaining the program. By ensuring that frontline staff are paid, this health system commitment allows us to focus our grant writing and fundraising efforts on sustaining key components that might otherwise be lost, including housing assistance, basic needs, and direct access to mental healthcare.
HVIP services are essential, but their implementation must be better understood, their outcomes more consistently assessed, and their foundations securely funded to provide reliable care for survivors of violence.
