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Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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3

Health Care Strategies to Reduce Firearm Injury and Mortality

The workshop’s first panel session on evidence-based health care strategies to reduce firearm injury and mortality featured three presentations. The panelists were Thea James from Boston Medical Center/Boston University School of Medicine, Rochelle Dicker from the University of California, Los Angeles, and Amy Barnhorst from the University of California, Davis. Following the three presentations, Frederick Rivara from the University of Washington moderated an open discussion with the three speakers.

Before introducing the first speaker, Rivara noted that despite the 25-year drought in federal funding for firearm research that resulted from the 1996 passage of the Dickey Amendment (Rostron, 2018), a number of individuals have spearheaded programs in which health care systems have collaborated with their communities to do primary, secondary, and tertiary prevention of firearm violence. These researchers, he said, have generated evidence that interventions can work and make a difference in reducing the burden of firearm injuries.

INVESTIGATING THE PIPELINE THROUGH COMMUNITY PARTNERSHIPS, INTENTIONALITY, AND COLLABORATION

To start her presentation, Thea James reiterated Rivara’s statement that hospital-based violence intervention programs are absolutely effective. “They really do alter the life course trajectory for victims of violence and produce healthy, stable, productive, and high-achieving citizens. They also slow down the pipeline from the perspective of recidivism,” said James. At the same time,

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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she said, the results of these programs would be even better if they addressed with real intentionality the actual root causes of the pipeline, because they only slow the pipeline, not stop it. For example, a study that compared neighborhoods in Boston based on where the city’s public transportation system had stops found correlations between lower income, premature death, lower education, lower life expectancy, and homicide rates. However, neither this study nor others like it investigated the findings to understand root causes.

In fact, said James, redlining policies, enacted during the 1930s during the Great Depression, created the neighborhoods that suffer from disparities in violence. Redlining refers to the historic practice of classifying neighborhoods according to how desirable they were from a mortgage-lending perspective, with neighborhoods with high concentrations of Black and low-income populations deemed “hazardous,” as noted by the color red on maps produced by the Federal Housing Authority (Figure 3-1). The effect of redlining was to prevent Black and low-income families from having access to home ownership and the benefits of home equity for building generational wealth, which created two distinct socioeconomic populations that still exist today.

The way the effects of redlining perpetuate today show up in the social determinants of health and health disparities, including the distribution of firearm injuries and stabbings by hospitals in the City of Boston. Boston Medical Center (BMC), a safety net hospital that serves many historically

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FIGURE 3-1 Federal Housing Authority’s practice of redlining denied mortgages to Black and low-income populations.
NOTE: In the official maps, green areas were designated as most desirable, blue still desirable, yellow as definitely declining, and red as hazardous.
SOURCE: James presentation, April 25, 2022 (Nelson et al., n.d.).
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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redlined, disinvested communities, received almost three times the number of patients suffering from gunshot wounds or stabbings than the next hospital (Table 3-1). Similar patterns occurred during the COVID-19 pandemic, said James, with Black and Latino/a individuals from historically disinvested neighborhoods being the majority of patients seen at BMC for firearm-related injuries. James said:

We all create programs to try to address the gaps [disparities] people have, but we do not eliminate these gaps, and when we do not eliminate these gaps, things do not really change in a very significant way.

The result, she said, is that despite having decades of experience developing models of care that address upstream drivers of health, there have been no changes in outcomes for health measures such as infant and mother mortality, diabetes mortality, deaths from cancer, incidence of depression and suicide attempts, and rates of homicides by firearms.

Beginning in 2018, James and her colleagues at BMC began asking whether the role of a safety net hospital is to perpetually fill gaps or to address equity issues. One realization they came to was that inequities are always present, but they are the status quo and look normal, so people do not investigate them. From surveying their patients who came from these communities, they realized they had two problems: access to care and distrust of the health care system, both among community members and the hospital’s employees who lived in those same communities. James noted that when the COVID-19 vaccines were released, they were not deployed to the areas that everyone knew would be most affected during the pandemic, so her institution decided to create its own access program.

TABLE 3-1 Individuals Seen for Gunshot Wounds or Stabbing by Hospital in Boston

Hospital 2020 2021 TOTAL
Boston Medical Center 465 359 824
Massachusetts General Hospital 176 114 290
Brigham and Women’s Hospital 83 67 150
Tufts Medical Center 57 69 126
Beth Israel Lahey Health 40 27 67
Boston Children’s Hospital 7 8 15
TOTAL 821 604 1,432

SOURCE: James presentation, April 25, 2022.

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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By speaking directly to community leaders and having infectious disease physicians and pharmacists of color speaking to these leaders, they were able to answer questions about the vaccine and figure out ways to create better access for community members; these included establishing six vaccination sites around the city. In addition, BMC had data revealing hotspots and vaccination status at the household level. “We would show up at people’s houses,” said James. Data also drove operations at the six vaccination sites and enabled the access program to intentionally increase vaccine outreach efforts where needed. As a result, Boston achieved higher vaccination rates in the targeted communities than the state did overall, demonstrating that progress toward equity is possible with an intentional focus on addressing racial inequities.

From James and BMC’s perspectives, the issue of equity comes down to economics and the ability of communities to thrive. To address this problem, her institution joined the Healthcare Anchor Network,1 whose goal is to build more inclusive and sustainable local economies through hospitals being intentional about how they hire, invest, and procure. As an example, when a hospital in Massachusetts adds onto a facility, the state requires that 5 percent of the total capital construction cost must go to the community. BMC petitioned the state to invest its 5 percent in multiple housing investment initiatives. The state approved this request, and BMC has invested $500,000 of its $6.5 million in a private equity fund that will only fund developers if their proposal provides access to employment, green walking space, transit, healthy and affordable food, and affordable housing. The first result is Bartlett Place, with 323 units of new mixed-income housing units, some of which are available to own and some to rent, and a grocery store owned, rather than leased, by two community members. Greater than 60 percent of the workers building Bartlett Place are from the community. BMC established the Boston Opportunity System Collaborative, which is using a JP Morgan Chase Advancing Cities grant to address systemic problems that drive differences in economic opportunity within segregated neighborhoods while using vibrant social connections within those neighborhoods.

James noted that the COVID-19 pandemic prompted Boston Medical System to look at every aspect across its entire enterprise—operations, research, education, its health plan—to look for and investigate inequities. More than 80 leaders across the organization engaged to develop a comprehensive initial approach to advancing health equity. Six working groups representing all areas of the enterprise listed equity-based actions they intended to pursue over the next 12 to 24 months. The actions would address and investigate inequity-based disparities, with the intention of identifying the root cause,

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1 Additional information is available at https://healthcareanchor.network/ (accessed August 10, 2022).

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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implementing an intervention, course correcting, and closing the gap. BMC engaged patients to add context to the data. It conducted in-depth patient interviews to better understand the patient experience and identify potential drivers of the observed inequities. From these interviews, the working groups developed a long-term vision, an “institutional transformation,” to advance health equity with clear strategic goals. It also created a prioritized list of 60 initial initiatives embedded across all areas of the system that are expected to produce results in the first 12 to 24 months.

James gave an example of a hospital’s institutional change that has had an impact. The obstetrics/gynecology department engaged in a quality improvement project that found that postpartum hemorrhage was happening more often in Black women. Upon close examination, staff realized that this was connected to preeclampsia, which was resulting from the fact that it was taking twice as long for a physician to decide to deliver the baby for Black women. The treatment for preeclampsia is to give birth. As a result, the department has now standardized the decision-making process, eliminating subjective decision making and closing this equity gap. Robust qualitative research is embedded in this work to better understand potential factors that created the disparity.

Today, BMC’s Health Equity Accelerator is working to transform health care to deliver economic justice and health justice across five areas: maternal and child health, infectious diseases, behavioral health, chronic conditions, and oncology and end-stage renal disease. James explained that this effort is progressing against a set of 2021 health equity priorities organized according to general clinical operations, high-inequity areas, social determinants of health, research and education, and advocacy, as well as talent, workplace, and culture. Informing this effort is its Equity Partnership Network, which includes a diverse, engaged group of Boston leaders and community members who provide guidance for BMC’s equity- and community-based initiatives. The entire effort, said James in closing, is focusing on the root causes of inequities to mitigate firearm violence and other adverse health outcomes as much as possible.

THE AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA’S ISAVE INITIATIVE

To begin her presentation, Rochelle Dicker explained that the American College of Surgeons Committee on Trauma is responsible for verifying and setting standards and indicators for trauma centers from level I to level IV. She then noted that structural racism, the root cause of inequities that James spoke about, is the normalization and legitimization of an array of dynamics—historical, cultural, institutional, and interpersonal—that routinely advantage

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

White people while producing cumulative and chronic adverse outcomes for people of color. One of those chronic outcomes, she added, is homicide.

Similar to the map James showed in her presentation (Figure 3-1), Dicker displayed a redlining map of Los Angeles County showing the redlined areas such as Compton and Lynwood (Figure 3-2). She then listed the social determinants of health and health outcomes that arise as a result of structural racism stemming in large part from redlining (Figure 3-3). Structural racism, said Dicker, explains the association between race and social class. She also reiterated James’s comment that without addressing the root causes of the social determinants of health, it will be difficult to greatly affect health outcomes. Dicker said:

The physical environment and social determinants, along with behavioral factors, drive 80 percent of health outcomes, with 20 percent being quality related and access related, but many of us would argue that you cannot have access, really true access, without addressing the social determinants.

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FIGURE 3-2 Federal Housing Authority mortgage lending map of Los Angeles County showing redlined areas.
SOURCE: Dicker presentation, April 25, 2022 (Nelson et al., n.d.).
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Image
FIGURE 3-3 Social determinants of health.
SOURCE: Dicker presentation, April 25, 2022 (Artiga and Hinton, 2018).

To illustrate the connection between social determinants of health, violence, and chronic disease, as well as the interconnectedness of health and wealth, Dicker presented maps of Los Angeles showing the overlap of areas with elevated environmental health risks, homicides, unemployment, amputations from diabetes, poverty levels, and food deserts by neighborhood (Figure 3-4). She noted that even though 85 percent of physicians report that unmet social needs lead directly to poorer health outcomes, only 20 percent of physicians are confident in their ability to address unmet social needs (RWJF, 2011). Dicker explained that it takes a community at the table as a partner to address these underlying social care needs; addressing the individual social needs goes part of the way upstream to root causes, but going all the way upstream requires strategies that address laws, policies, and regulations that create community conditions capable of supporting the health of all people.

Prior to the COVID-19 pandemic, the American College of Surgeons held a medical summit on firearm injury prevention that included representatives from the American Bar Association, emergency medicine, public health, and other stakeholders (Bulger et al., 2019). The summit’s discussions, which focused on different public health interventions and the role the organizations attending could play in preventing firearm injury, led to the American College of Surgeons Committee on Trauma establishing the Improving Social Determinants to Attenuate Violence (ISAVE) workgroup. This workgroup, in turn, developed

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

a set of strategies that trauma centers could employ to address the root causes of violence (Dicker et al., 2021). Dicker said that ISAVE has four main themes:

  1. Develop a nimble curriculum for trauma-informed care.
  2. Create a road map for investment in at-risk communities.
  3. Integrate social care into the medical system.
  4. Characterize the medical center’s role in advocacy around the social determinants of health and equity.

Trauma-informed care, said Dicker, accounts for adverse childhood experiences and honors the fact that these exist in many violently injured patients. It also recognizes that many patients experience toxic stress resulting from prolonged, strong activation of the body’s stress response system without having the counterbalance of supportive relationships to buffer that response. Toxic stress, in turn, negatively affects learning, behavior, brain development, and metabolic systems, and it can lead to the development of stress-related physical and mental illness (Shonkoff and Garner, 2012).

The trauma-informed care curriculum that ISAVE developed has six goals:

  1. Identify and define trauma and its characteristics.
  2. Identify and define the three Es of trauma—events, experience, and effect—and the four Rs—realization, recognize, respond, and resist retraumatization.
  3. Identify and define the different types of trauma that exist.
  4. Identify the characteristics of a trauma-informed lens.
  5. Identify the characteristics of trauma-informed care.
  6. Identify how to render appropriate support.

This curriculum is based on the understanding that trauma is a difficult or unpleasant experience that causes someone to have mental or emotional struggles over time, and it is informed by the Substance Abuse and Mental Health Services Administration’s six principles of trauma-informed care (SAMHSA, 2014):

  1. Physical and emotional safety,
  2. Trustworthiness and transparency that creates a space for human connection through up-front communication,
  3. Peer support that integrates credible messengers,
  4. Collaboration and mutuality that creates a model for respect and equitable care and responds to concerns,
  5. Empowerment and choice that allows survivors to play a critical role in medical decision making and healing, and
  6. Recognizing and addressing cultural, historical, and gender issues.
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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The trauma-informed care curriculum emphasizes a systematic approach. It starts with the idea that hospitals are trauma informed at a comprehensive level when hospital personnel practice trauma-informed care and exemplify the Beloved Community;2 when trauma-informed care is integrated into hospital policy and physical layout—waiting rooms with water, tissues, and clean spaces to sit, for example; and when trauma-informed care is woven into the practice of all of the hospital’s staff, including clerks, security personnel, administrators, and anyone else who comes into contact with trauma victims. The curriculum includes a segment on vicarious trauma, which recognizes that physicians, nurses, and other clinicians may experience vicarious trauma that can contribute to taking a nontrauma-informed approach with patients on occasion. Dicker noted that the curriculum includes a lived experience expert. Fifteen trauma centers across the nation will be piloting this curriculum during summer 2022. Data collection and analysis will lead to a second version of the curriculum that ISAVE will disseminate widely.

ISAVE has also developed a road map for investment in at-risk communities. This road map is based on a vision that health care centers will take an active role in altering people’s life course toward a path of independence, including economic independence, and freedom from violence and chronic disease. Strategies to realize this vision include building external partnerships, providing opportunities for the community to have a voice, and retooling formal and informal medical education. Health systems can also leverage the Affordable Care Act’s community health needs assessment and community benefits programs, as well as push for value-based care.

The third theme for ISAVE’s efforts is to adopt a social care mission with two goals. The first is to provide tangible and working examples of the integration of social care into medical care. The second is to outline mechanisms by which hospitals can train, finance, and operationalize this integration. Along these lines, said Dicker, hospitals could design care delivery to integrate social care into health care, with hospital-based violence intervention programs being an example of a community-based violence intervention that engages credible messengers from the communities affected by violence as well as violence prevention professionals. Hospital-based violence intervention programs also provide long-term, culturally competent case management, provide links to risk-reduction resources, and seize teachable moments. Building a hospital workforce that can integrate social care into health care delivery and

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2 The Beloved Community, a term first coined by Josia Royce, is a global vision expressed by Dr. Martin Luther King, Jr., in which all people can share in the wealth of Earth. In the Beloved Community, everyone is cared for absent of poverty, hunger, racism, bigotry, prejudice, and hate (The King Center, n.d.).

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

fund, conduct, and translate research and evaluation of social care integration models are additional steps that can be taken.

Dicker mentioned two important resources: a National Academies consensus study report, Integrating Social Care into the Delivery of Health Care, that provides a road map for moving upstream to improve the nation’s health (NASEM, 2019), and a primer on violence intervention programs for trauma centers released by the American College of Surgeons (Dicker et al., 2017). She also pointed out that the Health Alliance for Violence Intervention can provide training and technical assistance and will be releasing standards and indicators for hospital-based violence interventions.3

On a final note, Dicker provided a case scenario to illustrate why social care is needed. In this scenario, a 23-year-old male is in the intensive care unit with a gunshot wound for 13 days. On discharge, he is ordered to return to follow up 1 week after leaving rehabilitation. To a physician, the discharge process may mean writing the order and preparing a discharge summary, but for the patient it means juggling a variety of concerns in order to make it to that follow-up appointment. The key, she said, is to have cultural humility and understand how to measure value by listening to the community that is most affected by social determinants of health. She calls this social technology—when all the stakeholders are at the table being listened to in a way that can lift up people and enable working upstream.

THE BULLETPOINTS PROJECT

BulletPoints, said Amy Barnhorst, is a firearm violence prevention curriculum project designed for health care providers. While involving health care providers in firearm injury prevention is not the only solution to this problem, they can play an important role in addressing the multiple causes of death and injury from firearms. In fact, most physicians feel that counseling falls within their clinical responsibilities, and most patients, including firearm owners, believe it is generally appropriate for their providers to talk with them about firearm safety and injury prevention particularly when there is someone in the home who is at risk of attempting suicide. However, providers overwhelmingly say they need more information to hold these conversations with their patients and intervene appropriately. For example, many clinicians say that when they find out that a patient is at risk and has a firearm at home, they do not know what steps to take to mitigate risk. Clinicians also report needing more information about identifying patients who are at risk so that they can have these conversations.

Barnhorst explained that the BulletPoints Project got started when Marc Berman, a California Assembly member who wanted to do something about

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3 Available at https://www.thehavi.org/ (accessed August 10, 2022).

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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firearm violence but was tired of the partisan political battles over firearm legislation, teamed up with Garen Wintemute, an emergency department physician who runs the California Firearm Violence Research Center at the University of California, Davis. Together, the two came up with the idea of developing a curriculum for health care providers to teach them how to address the risk of firearm injury and death affecting their patients. Spurring this effort, she said, was the National Rifle Association’s November 2018 comment via Twitter that “someone should tell self-important anti-gun doctors to ‘stay in their lane’”4 and the tweeted replies from the trauma and emergency medicine community talking about what happens in their lives and their work as a result of firearm violence. This outcry helped lead to the passage in California of AB521, which appropriated almost $4 million for developing, evaluating, and disseminating curriculum for physicians, surgeons, and other medical and mental health providers on firearm injury prevention in the health care setting.

The nine member, multidisciplinary BulletPoints team includes emergency medicine physicians, mental health professionals, a researcher with experience researching and evaluating large public health programs, and analysts with experience in evaluation, research, public health, and public communication. The team works with other clinicians, as well as experts who have experience in areas such as public health education and firearms research. The team has focused its curriculum on health care providers and health care educators, with the endpoint target being firearm owners, given that they are the people most at risk of firearm injury, suicide, and death. The idea has been to educate health care providers in a politically neutral manner using evidence-based materials. Barnhorst said:

We encourage folks who attend our lectures and take our courses to keep their own personal politics, views, and or opinions about firearms out of the conversation, and instead focus on risk and the particular situation of the patient they are with at the time.

BulletPoints takes a culturally humble approach with an eye to the social determinants of health. The idea behind this approach, said Barnhorst, is for the clinician to put themselves in the shoes of a patient who may have a different political view, background, experience, and concerns while keeping in mind some of the social determinants of health that contribute to the risk of firearm injury. For example, people may own a firearm for a variety of reasons, with the most common in the United States being for protection. “So

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4 Available at https://twitter.com/nra/status/1060256567914909702?lang=en (accessed August 10, 2022).

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

while you may be aware that the biggest way to reduce risk might be to get the firearm completely out of the home,” said Barnhorst, “oftentimes we have to work with folks using cultural humility and a harm-reduction approach to talk about what would be a good way that is acceptable to them to reduce the risk of firearm injury in their home and that they are willing to enact.” For example, if they are not willing to remove all firearms from the home, a biometric lock box kept inside the home may be an effective compromise.

One thing the project team learned during the COVID-19 pandemic was the need for the program to be flexible as needs emerged. Before the pandemic, the idea was to hold in-person conferences and symposiums and attend grand rounds, but the program quickly shifted to an online platform and creating on-demand educational videos and recordings of program webinars, as well as focusing on its website as a place to disseminate material.5 This turned out to be a good decision for the long term because it will leave a legacy in the form of a body of knowledge that will remain available to people who are working in health care and are interested in reducing firearm injury.

Material on the website is organized in sections titled The Basics, Clinical Scenarios, Interventions, and More Resources. The Basics section, for example, goes through some of the principles for how to counsel patients at risk of firearm injury in a way that is culturally humble and takes a harm-reduction approach. It also includes information about the epidemiology of firearm violence, the people it affects, and the disparities of who it affects, as well as information about firearms themselves for clinicians who do not have experience with firearms, laws relating to firearms and how they may apply to patients in the mental health system, the social determinants of health, and the principles of cultural humility.

The Clinical Scenarios section, said Barnhorst, contains scenarios that mental and medical health care providers may encounter with patients whose risk of firearm injury is elevated by the presence of a firearm in their homes. This includes scenarios on suicide, intimate partner violence, threats of mass shootings or mass violence, and dementia, all situations where a firearm in the mix may increase the risk of firearm injury or death. The scenarios provide the clinicians with a sense of how firearms may play a role as well as some of the steps that the clinician can take to reduce that risk.

The Interventions section, which includes links from the clinical scenarios, provides details on possible interventions as a means of empowering clinicians to ask their patients about their access to firearms. The interventions are presented in a risk-stratified manner, starting with safe storage, which is a good thing to counsel patients about if they own firearms regardless of whether or not someone in the home is at acute risk, said Barnhorst. They then move

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5 Available at https://www.bulletpointsproject.org/ (accessed June 30, 2022).

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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to interventions for riskier scenarios, such as temporarily transferring firearms out of the home at times of suicide risk or determining when a mental health hold is appropriate, and discuss how those steps might affect somebody’s status in terms of being prohibited or not prohibited from owning or purchasing firearms. This section also discusses when civil protection orders are appropriate, so-called Tarasoff statutes, that require mental health professionals to warn a third party that they may be at risk of serious bodily injury from a client who threatens violence, and hospital-based violence intervention programs of the sort that James and Dicker covered in their presentations.

Barnhorst explained that BulletPoints uses a variety of avenues for delivering its content beyond its website and various lectures, presentations, and monthly webinars. BulletPoints has a newsletter and a blog featuring contributions from experts on firearm violence, and it makes extensive use of social media. It is also developing a continuing education course, sponsored by the American Psychological Association and the American Medical Association, and has created an educator’s toolkit. She noted that medical schools from outside California have requested presentations, and she and her colleagues have conducted grand rounds at a number of organizations and medical societies across the country. The team has also published a number of peer-reviewed journal articles on the role of health care providers in suicide and firearm injury prevention (Barnhorst et al., 2021; Hoops et al., 2022; Pallin and Barnhorst, 2021; Pallin et al., 2022; Wintemute et al., 2022).

DISCUSSION

An audience member asked whether there are databases for temporary firearm storage locations. Frederick Rivara answered that there is a map of police stations, shooting ranges, and retail outlets for Colorado and Washington, and that there is an ongoing effort to develop a toolkit for other states to use to develop their own maps. Another audience member asked whether there are clinically validated risk and protective factor assessments for use with patient populations. All three speakers said that such instruments do not exist and would be difficult to develop because the risk of firearm injury and firearm death and psychological consequences of firearm violence are so individualized and varied.

Responding to an audience question about how hospitals can approach violence intervention with cultural humility, Dicker said there are two things that hospitals can do. First, educating people in a trauma-informed manner is essential, and second, integrating the community into the hospital and the healing process. “Once you start to do that, you see that the people who are caring for individuals pay attention, and they see the right way to go about addressing patients, not just keep them alive but help them to thrive,” said

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

Dicker. It is also important, she added, to deliberately create a pipeline of providers who are from communities affected by violence and who already have the cultural humility that is necessary for this type of care. James agreed that trauma-informed care is extremely important because it is easy to inadvertently retraumatize people when a clinician does not understand that some of their behavior is a manifestation of trauma.

When Barnhorst was asked whether the BulletPoints Project was willing to share its curriculum with other hospitals, she answered, “absolutely yes.” All of the content is available online with the goal that others borrow and use it. She added that because the project involved a terrific panel of experts to develop these materials, there is no need to reinvent the wheel.

Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×

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Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
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Page 17
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 18
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 19
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 20
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 21
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 22
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 23
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 24
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 25
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 26
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 27
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 28
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 29
Suggested Citation:"3 Health Care Strategies to Reduce Firearm Injury and Mortality." National Academies of Sciences, Engineering, and Medicine. 2022. Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative. Washington, DC: The National Academies Press. doi: 10.17226/26707.
×
Page 30
Next: 4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities »
Integrating Firearm Injury Prevention into Health Care: Proceedings of a Joint Workshop of the National Academies of Sciences, Engineering, and Medicine; Northwell Health; and PEACE Initiative Get This Book
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The staggering number of deaths and emergency department visits caused by firearm injuries has only grown with time. Costs associated with firearm related injuries amount to over a billion dollars annually in the United States alone, not including physician charges and postdischarge costs.

To address this epidemic, in April of 2022, the National Academies of Sciences, Engineering, and Medicine's Board on Population Health and Public Health Practice, in collaboration with Northwell Heath and the PEACE Initiative, brought together firearm injury prevention thought leaders to explore how health systems can integrate interventions for firearm injury prevention into routine care for the purpose of improving the health of patients and communities. The workshop speakers discussed strategies for firearm injury and mortality prevention and its integration into routine care. Speakers also explored facilitators and barriers to implementation strategies, and how health systems might work to overcome those barriers.

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