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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 (2022)

Chapter: 4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities

« Previous: 3 Health Care Strategies to Reduce Firearm Injury and Mortality
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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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4

Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities

The workshop’s second session featured presentations by five panelists: Rinad Beidas, University of Pennsylvania; Ashley Hink, Medical University of South Carolina; Scott Charles, Temple University; and a joint presentation by LeVon Stone and Sheila Regan, both from Acclivus. Andre Campbell, from the University of California’s San Francisco School of Medicine, moderated a brief discussion following the presentations.

IMPLEMENTING FIREARM SAFETY PROMOTION PROGRAMS IN PEDIATRIC PRIMARY CARE

Rinad Beidas opened the session with a position statement, noting that she identifies as an implementation scientist. That, she explained, means that she uses insights from behavioral economics and implementation science to make it easier for clinicians, leaders, and organizations to use best practices to improve the quality and equity of care and enhance health outcomes. “I see implementation science as a way to advocate and amplify the needs of our communities and the pursuit of achieving population health and social justice at scale,” said Beidas. She also said she is a Middle Eastern immigrant, mother, community member, and practicing psychologist in pediatric anxiety, identities that influence her perspective.

Implementation science is the scientific study of methods to promote the integration of various evidence-based practices, interventions, and policies into routine health care to improve population health, Beidas explained (Lane-Fall et al., 2019). She commented that addressing the research-to-practice gap

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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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is a major challenge today and that the time for equitable implementation has arrived. As an example, she cited a simulation study published before COVID-19 vaccines gained emergency use authorization showing that the implementation challenges that vaccination efforts would face were as important as the efficacy of the vaccine (Paltiel et al., 2021). She also cited a second paper calling for a new lane for implementation science based on the fact that COVID-19 has shown the world that knowing what to do does not ensure doing what we know (Proctor and Geng, 2021).

Several years ago, Beidas and a colleague developed a heuristic tool called the implementation science subway that explains the type of questions implementation science asks (Figure 4-1) (Lane-Fall et al., 2019). The first step is to identify the practice of interest, such as an intervention that might reduce the effect of firearm injury or mortality. That leads to the first question and decision point: Has the practice of interest been tested in tightly controlled settings and shown to reduce the poor health outcome of interest? If the answer is no, then the next step is to conduct an efficacy trial designed for implementation. “You want to make sure you have community members who can tell you if the thing you are trying to develop is acceptable, appropriate, and feasible,” said Beidas, “but that is pre-implementation work” (seen as the red line in Figure 4-1).

If the answer to that first question is yes, the next question is whether the intervention works in a less tightly controlled setting using real-world populations and real-world clinicians. If the answer is no, the next step is to do effectiveness research in the real world, and again, that by itself is not implementation science. If that study aims to understand implementation barriers or facilitators or implementation processes, that is something that implementation scientists call a hybrid effectiveness–implementation trial. A yes answer

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FIGURE 4-1 The implementation science subway.
SOURCE: Beidas presentation, April 25, 2022 (Lane-Fall et al., 2019).
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

to that second question leads to what Beidas called the bread-and-butter work of implementation science—conducting mixed method studies to understand context, designing strategies to implement evidence-based interventions, and testing those strategies in comparative effectiveness studies.

Turning to the subject of her current work in firearm safety promotion, Beidas emphasized that this work is ongoing. She explained that the firearm safety promotion team is trying to understand scientifically how to implement an evidence-based firearm storage program in pediatric primary care as a universal suicide prevention strategy and promote it across health systems nationally. The problem to address, she said, is that suicides are increasing among young people in the United States (Curtin et al., 2018). Simulation work has shown that an increase in secure firearm storage could prevent up to 32 percent of firearm deaths in youth (Monuteaux et al., 2019). In addition, there is an evidence-based practice developed for pediatric primary care called the Safety Check that includes, among other components, screening for firearms in the home, having a brief conversation between a parent and a pediatric care provider, and offering free cable locks (Barkin et al., 2008; Ip et al., 2011). This, said Beidas, is the practice of interest, and the answer to the first question on the implementation subway is yes—there has been an effectiveness study showing that this intervention increases patients’ secure firearm storage. Beidas said:

That takes us squarely down the implementation science subway line to start trying to understand barriers and facilitators to implementing this program in pediatric primary care because we know that it is not being used widely despite its effectiveness and endorsement by the American Academy of Pediatrics.

Using an implementation science framework called the Consolidated Framework for Implementation Research to elucidate those barriers (Damschroder et al., 2009), Beidas and her colleagues learned that any program for pediatric primary care must be short for it to be deployable, that it must be integrated into the workflow using the electronic health record, and that leadership must be onboard (Benjamin Wolk et al., 2018). They also learned there are varying levels of self-efficacy and comfort among clinicians delivering such a program, and they gained insights about the broader sociopolitical context needed to account for the firearm culture and the communities in which they were implementing the intervention.

After conducting this rich, contextual inquiry using quantitative and qualitative measures, Beidas and her colleagues did something she called implementation mapping (Fernandez et al., 2019). This systematic process allowed them to derive a set of implementation strategies that they could then test in an implementation study. These strategies involved a number of steps,

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

including creating a plan for who on the team would be responsible for implementing each component, integrating the program into the electronic health record, and adapting the program for use as a suicide prevention program for older youth who were not in the age range for which Safety Check was developed (Davis et al., 2021a,b). Beidas and her colleagues also learned from community stakeholder input that the program needed additional adaptations to enhance its acceptability, appropriateness, and feasibility, and that it had to focus on suicide prevention.

Using the systematic adaptation process, the team emerged with a new program name, Safe Firearm, and logo that were crowdsourced using parents who are firearm owners (Davis et al., 2021a). They also learned from stakeholders that screening for firearms was less acceptable than having a conversation and offering cable locks to everyone as a universal strategy, which is how they now deliver the program. Beidas and her colleagues are now doing a large implementation study in Michigan and Colorado to test whether a less costly and scalable electronic health record–based nudge for clinicians reminding them to deliver the program is as effective as a more intensive and expensive facilitation (Beidas et al., 2021). The latter, said Beidas, is a more resource-heavy strategy to overcome implementation barriers. On a final note, Beidas explained that as part of a pilot prior to launching the trial, she and her colleagues are looking at signals for inequities to inform their approach to design for equitable implementation (Baumann and Cabassa, 2020; Shelton et al., 2020, 2021).

HOSPITAL AND COMMUNITY VIOLENCE INTERVENTION PROPAGATION IN THE SOUTH: UNIQUE NEEDS, CONSIDERATIONS, AND CHALLENGES

The experience of firearm violence, specifically homicide and assault, is different in the South relative to the rest of the nation (Figure 4-2), said Ashley Hink. She added that states with weaker firearm safety and responsibility laws tend to have higher rates of violence, which is true in her state of South Carolina, though this is not the entire story. South Carolina, with the fifth highest firearm homicide rate in the United States, at 11 homicides per 100,000 residents annually, bears a particular burden, with 85 percent of all homicides in the state committed using a firearm. Firearm homicides in the state, said Hink, have more than doubled over the past 10 years, from 229 in 2010 to 528 in 2020, and in Charleston alone, homicides increased 100 percent in 2020. “We truly have a major problem here,” she said.

Homicide is the leading cause of death in the state for Black youth and young men, who are 7.4 times more likely to die from homicide than White youth and young men, said Hink, and firearm injuries are now the leading

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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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FIGURE 4-2 Firearm homicide rates by state per 100,000, 2020.
NOTE: Firearm homicide rates are age-adjusted.
SOURCES: Hink presentation, April 25, 2022; CDC WISQARS, 2020.

cause of death for children and teens in the state, with most of these injuries resulting from assault (Andrews et al., 2022). South Carolina has also ranked in the top 10 states for the number of murders resulting from intimate partner violence since data were first compiled, and in 2020 the state ranked sixth in the nation.

When breaking down risk factors at both the individual and neighborhood level, Charleston does not look that different from other urban, densely populated areas in the county. What is different, said Hink, is that urban and rural areas are both plagued by firearm violence. Poverty, intergenerational violence, lack of access to employment, and being underinsured, as well as an abundance of easy to access firearms, are some of the factors that affect rural areas as much as urban areas. The Area Deprivation Index—an index that pulls together aspects of income, education, housing, equality, employment, and more—shows this clearly (Figure 4-3) (Kind and Buckingham, 2018). However, she added, some regions of the state with the highest homicide rates are those with the highest deprivation (as seen in red in Figure 4-3).

The Medical University of South Carolina (MUSC), Hink’s institution, is a level I trauma center for both adult and pediatric patients. In 2021, the trauma center treated more than 350 victims with gunshot wounds, 30 percent from the City of Charleston, 40 percent from the City of North Charleston, and 30 percent from the surrounding areas, which include some rural areas and small towns. In comparison, the City of Boston had 198 victims with gunshot wounds in 2021, a 28 percent decrease from the year before (Boston Police Department, 2022). What makes Charleston and South Carolina different, said Hink, is that there are no dedicated state funds for violence intervention, no use of American

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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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FIGURE 4-3 Area Deprivation Index for South Carolina, with red areas being the most disadvantaged regions and blue the least disadvantaged.
SOURCES: Hink presentation, April 25, 2022; Kind and Buckingham, 2018; University of Wisconsin School of Medicine and Public Health, 2019.

Rescue Plan funds for community-based or hospital-based violence intervention, no Medicaid expansion, limited city or county investment in violence prevention, and some of the least stringent firearm laws in the United States. Hink said:

Not only are we struggling to find ways to actually pay for this work, but almost 70 percent of our victims of violence do not have health insurance, and so we see major barriers to care and access after they are injured and need ongoing care and support.

Nonetheless, her institution has implemented a hospital-based violence intervention program despite those barriers.1 The Turning the Tide Violence Intervention Program got its start when the chair of the Department of Surgery, along with individuals in the Provost Office and MUSC, realized that the institution needed to do more to address this problem with

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1 The American College of Surgeons requires that all trauma centers must have an injury prevention program and meet specific requirements (ACS, 2022).

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

evidence-based strategies.2 Hink and her colleagues identified allies and partners with shared interests and gathered local data on firearm violence in order to inform efforts and better communicate to the public the burden of firearm violence, and the need for and lack of investment in preventing firearm assaults and homicides. After securing financial support from the School of Medicine, the Provost Office, and the Department of Surgery, as well as using some state health department funds the trauma center receives for treating uninsured patients, Hink and her colleagues partnered with the Health Alliance for Violence Intervention (HAVI) to help start the program and train staff on violence intervention strategies. She added that program team members worked hard to integrate the program into clinical care and educate their colleagues and students. They also started celebrating the project and drawing attention to it to garner more support and resources to fund future efforts from philanthropic efforts and grantors (e.g., City of North Charleston Community Needs Grant and Dominion Energy).

Hink explained that the program’s three frontline staff members were all born and raised in the Charleston area and have been involved in violence intervention work in their neighborhoods. In doing their work, they have support from injury prevention coordinators, as well as liaisons in pediatrics, pediatric surgery, and emergency medicine. In addition, her team has partnered with many local organizations to provide a wide range of long-lasting services and wraparound support for patients ages 12 to 30 with risks for, or injuries from, community violence in the Charleston tricounty area. Those services and supports include family support, victims of crime assistance, medical services, educational support, arts and music programming, employment and occupational training, mental health services, and a trauma resilience program. She noted that the program cannot provide the same level of intensive support for patients from outlying and rural areas, but it can provide some support and advocacy and connect those individuals with resources and referrals in their communities.

While that reduced level of intervention provided to patients in outlying areas may not be as meaningful in terms of outcomes that other hospital-based violence prevention programs have demonstrated, Hink said that many patients, no matter where they come from, report that they have benefited from the program and find the support and care they do receive is profoundly meaningful. One client, she recalled, said that the program “made him feel like a human being” after the program helped him secure a job, get his driver’s license, and open a bank account. Since July 2021, the program has served more than 90 individuals and families and enrolled 42 individuals for long-term support.

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2 Available at https://muschealth.org/medical-services/emergency/trauma/turning-the-tide (accessed June 30, 2022).

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

One role the program plays, said Hink, is to propagate trauma-informed care, which involves changing the mindset of hospital staff in terms of what the victims of violence look and sound like and getting them to shift the focus from “What’s wrong with you?” to “What happened to you?” This effort involved a significant amount of education and outreach to staff, students, and hospital leadership. It also involved getting the principles of trauma-informed care engrained in the medical school curriculum and into the fabric of the hospital community.

Hink noted that the City of Charleston is going through a revitalization effort that is changing the landscape of low-income housing, improving parks, creating green spaces, and renovating public housing units. Using data on violence at the neighborhood level, the Turning the Tide Violence Intervention Program focuses on areas that have the highest number of assaults involving firearms and partners with Youth Advocate Programs, Inc. (YAP) that have a history of propagating community violence interventions in those neighborhoods, in addition to other community organizations participating in community violence interventions. As a partner on a grant, YAP also coordinates with other organizations to provide wraparound services to youth identified by the school system, juvenile justice system, solicitor’s office, law enforcement, and nonprofits as being at high risk of violence in order for YAP to act in a prevention capacity rather than as an intervention.

Advocacy as a means of raising awareness about community violence intervention is a significant part of the program. Team members have engaged with the community, given presentations to local organizations, and testified to, and held frequent conversations with, local elected leaders. Team members and other clinical staff have written newspaper editorials; participated in multiple educational events, grand rounds, and June 4 Wear Orange Day activities; and worked to introduce pediatric staff to other evidence-based programs such as safe firearm storage screening and use of cable locks. The overall goal is to become engaged in the community.

In closing, Hink said that one of the candidates for governor of South Carolina has included violence prevention and reduction strategies as part of their campaign platform, while a colleague of hers is running for Congress as a result of her passion for reducing firearm violence. Hink said:

This is not meant to be an endorsement but to say that we have to be involved in advocacy in order to educate our leaders and to help propagate this work, especially in places like ours where it is not happening and is so desperately needed.

She also noted that following the epidemiology of violence shows that while certain populations and urban centers suffer a disproportionate burden,

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

the U.S. Southeast has a profound disparity and lack of investment that is not matching need. Hink said:

Many roads to eliminating violence disparities lead to the South, and our patients, our communities, and our health care systems deserve this [an investment in violence prevention]. We need to be propagating, supporting, and investing in evidence-based and evidence-informed violence interventions. It can be done, and we are excited that we have been able to do this work here.

TEMPLE UNIVERSITY HOSPITAL’S CRADLE TO GRAVE PROGRAM

Over the course of 4 years, Temple University Hospital went from treating just under 400 victims of shootings in 2016 to more than 850 in 2020, which Scott Charles said makes it difficult to feel good about the work he and his colleagues are doing to prevent firearm injury and death. Nonetheless, he added, he and his colleagues are determined to keep going and depend on the insights of those attending this workshop to inform their efforts.

Charles recounted how he came to be in charge of developing a firearm injury prevention program at a hospital after 17 years of working on community-based youth programs. In 2005, he had a chance encounter with Amy Goldberg, a trauma surgeon at Temple Health who was frustrated by the fact that the only time she encountered young people was when they entered the hospital as victims of violence. That encounter led to Goldberg tapping him to develop the type of initiatives he had been developing in communities across the nation. The next year, Temple University Hospital launched the Cradle to Grave program with the goal of deglamorizing gun violence through an immersive experience that would enable young people to appreciate the real-life consequences of gun violence without them having to suffer those consequences firsthand.3

The program brings young people into the hospital for a 2-hour presentation that includes discussions about the real-life events surrounding the shooting death of a local teenager. Young participants also visit the trauma bay, where medical staff explain the procedures they undertake to try to save a shooting victim’s life. A classroom session also informs the participants about how gunshot injuries are treated, after which the participants engage in a series of reflective exercises that asks them to discuss the people they love, the people who love them, and how gun violence has affected their lives. Since 2006, said Charles, more than 14,000 young people have participated in the Cradle to Grave program.

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

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

Charles said he is incredibly grateful for the way Temple Health has come to embrace this work as part of its mission, particularly given that many years and several leaderships ago, talking about the gun violence that surrounded the hospital was discouraged for fear that it would scare patients away and hurt the hospital’s finances. “I am glad to say that my stubbornness has allowed me to outlast those individuals,” said Charles.

One thing he learned about creating a hospital-based program during those years was the need to make people uncomfortable. By nature, he said, hospitals like routine and order and are reluctant to do things differently. As a result, it can be difficult for people to envision the role that a hospital can play in addressing the issues that exist outside its walls. He acknowledged that this attitude is changing, but lack of imagination is still one of the greatest challenges he and others face when trying to establish new programs. He also noted the emphasis leadership places on evidence-based programs, which he understands is important, but the idea that the next hospital program be largely based on the last hospital program is a threat to innovation. “Yes, we are here at this forum because the landscape is changing and more and more we recognize the link between gun violence and public health,” said Charles. “But we are also here because we have not yet found the solution.” In fact, he added, in places such as Philadelphia, with a rich history of violence prevention programming, the situation is worse than ever today.

Charles then recounted how in 2014 he received a phone call from a man named Wayne Jacobs who lived in north Philadelphia, a few miles from the hospital. Jacobs told him that in the decades since his release from prison, he had devoted his life to helping returning citizens reintegrate into society and trying to prevent gun violence. He was calling that day because he and others from his community were tired of watching helplessly as they waited for assistance to arrive for young people who had been shot. “Wayne wanted to know if there was some way for staff from the hospital to teach him and his neighbors how to lend medical assistance to shooting victims,” said Charles. “I remember staring at the wall thinking, ‘well, that is a crazy idea,’ and then being struck by the thought that it was such a crazy idea that it just might work.”

To see whether this idea would work, Charles approached Tim Bryan, an emergency medicine resident, a former respected Navy medic who had taught combat medicine all over the world. Bryan’s reply was that not only could it be done, but also that it had to be done. Over the next year, Charles and Bryan met with Jacobs and other community members to get their ideas regarding a community-based first aid program. Two of the community members’ concerns were that the program not be overly complicated and that they did not want to be shot by police who might mistake them for robbers going through the victim’s pockets.

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

The 2-hour course that Bryan and Charles developed is known as Fighting Chance.4 During the course, volunteer nurses and physicians work with local organizations to train residents to help save friends, neighbors, and family members in communities that are plagued by gun violence. Since its inception, the program not only has trained thousands of local residents, but also has been used to train violence interrupters, school staff, and law enforcement officers. In 2015, Fighting Chance was one of the only nongovernmental entities invited to the White House for the launch of the Stop the Bleed campaign.

Charles noted that the reason he told this story was that while it is important to listen to experts, often the real experts are community members who have not read a single article in a refereed journal and are often absent from the room when the experts conceive their ideas about what is best for the community. Community members, he said in closing, typically have the very insights that “we at large institutions will devote countless hours and endless amounts of money trying to gain,” yet authentically integrating the community voice and perspective into gun violence interventions is one of the most persistent challenges to overcome.

ACCLIVUS VIOLENCE PREVENTION SERVICES

Acclivus’ mission, explained Sheila Regan, is to support community health and well-being for Chicago-area populations that are at risk for violence and other negative health outcomes. Its vision is to provide all individuals with the opportunity to reach their full human potential regardless of past misdeeds, disappointments, or challenges that are influenced by internal and external causes. She reiterated Charles’s comments about the importance of having an authentic community voice in the room that drives these programs. That has been critical for Acclivus as a community health organization that provides targeted health education grounded in public health methods.

Regan and her colleagues use data-driven interventions based on multiple data sets, including data the company collects and government and hospital data sets. They take a public health approach because public health is by its nature an intentionally interdisciplinary and inclusive framework that allows for respectful understanding of different professional roles across community-based organizations, health care institutions, government agencies, and law enforcement. “Everyone has a role in a positive and effective public health campaign,” said Regan. A public health approach is also intentionally practical and efficient, easily digested by any population, and provides a role for each person involved.

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4 Available at https://www.templesafetynet.org/fightingchance (accessed on August 5, 2022).

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

All members of the company’s leadership team are grassroots leaders who are committed to and invested in seeing positive outcomes for Chicago and who each have more than 20 years of experience in violence prevention and reduction work in Chicago. Though Acclivus focuses on Chicago, Regan noted that she and her copresenter, LeVon Stone, have also provided national and international trainings on hospital-based violence prevention programs. She also pointed out that Stone started doing this work in 2005 as a hospital responder and has since earned his bachelor’s and master’s degrees. As chief executive officer and founder of Acclivus, he can show the target audience that it is not how they start, it is how they finish, and that it is never too late to be the person they really want to be. Recently, she added, the company received a grant from the state of Illinois to provide violence prevention training across the state to different service providers.

The company performs its community violence prevention work at seven sites across Chicago. The primary services it provides are conflict mediation and case management with individuals who are at highest risk for becoming involved in violence. The hospital intervention program responds 24 hours a day, 7 days a week, to victims at five hospitals, as well as offering a variety of supported programs in the community that are complementary and support the same target population. For example, Acclivus supplies behavioral health services, and trauma-informed, culturally competent therapy provided by therapists from the affected communities. The program also has access to justice programs that connect individuals to legal resources focusing on reentry needs for individuals who are reentering the community from jail or prison and eviction prevention for people who might be experiencing housing instability. Regan and her colleagues also serve on various local coalitions and task forces focused on victim services, health care services, and public health issues. Currently, Acclivus is involved in 11 different research projects in partnership with five different universities. The company also provides technical assistance for 23 emerging grassroots organizations, with others coming on board.

Within 1 hour of receiving a call, someone from the organization is at a patient’s bedside to support the individual and loved ones. Acclivus then networks with community-based resources to provide violence interruption and conflict mediation in real time anywhere in the city. In 2021, Acclivus served 2,628 of the city’s 3,561 gunshot victims, along with 556 visitors at the patient’s bedside. The latter figure, said Regan, was lower than expected in an average year because the COVID-19 pandemic restricted who could visit the patient. In a normal year, the organization serves twice as many visitors as patients. She noted that the median age of a person being shot is under 30 years, and while every population is affected by gun violence, no one is affected more than Black men (Giffords, n.d.; Kaufman et al., 2021).

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

DISCUSSION

Andre Campbell opened the discussion by asking the panelists how they fund their operations. Stone replied that most of the funding for Acclivus’s programs come from the state of Illinois thanks to a line item in the state budget. Aggressive fundraising brings in additional funds from philanthropic organizations and hospitals. He noted that the organization has arranged for tuition reimbursement for program staff. When Campbell asked how they managed to get a line item in the state budget, Regan replied that it was through the organization’s commitment to advocacy and building strong relationships with state leadership. “They know us, they know we are accountable, and that we are going to do right by every dime,” said Regan.

Charles said that Pennsylvania has recognized what was happening in Philadelphia and elsewhere in the state and has begun to provide funds for these types of programs. However, sustained funding can be a challenge. Three years ago, for example, his hospital launched a 24-hour, hospital-based crisis responder program that receives state funding. The main issue, he said, is that funding usually only lasts 2 to 3 years, after which he has to look again for money to pay for the program. This is a particular problem, he said, for the grassroots or community-based programs with which programs such as his want to partner.

Hink explained that her program, the only one in the state, has had to piece together funding sources and look for funds every year, and she called out state leaders for not recognizing the needs to address one of the highest homicide rates in the United States. “Every day is a mass violence day in our state, and so we have to bring attention to and advocate for our patients and communities and say that this work is so important that it should be funded,” said Hink. “This should be a line item everywhere, because we should care about people dying from violence.”

Campbell then asked Beidas how she ensures that there is equity integrated into the various steps of the implementation subway. She replied that in the beginning, implementation science was not as explicit about the need to include equity, but in the past few years that has become explicit. To integrate equity her team first understands the potential inequities that might exist prior to deploying an intervention by identifying them and then tracking and measuring them to make sure they are not creating new inequities. They also deploy strategies to reduce inequities while doing the work. For example, suicide rates among Black individuals are increasing rapidly, so her team looks at that population when extracting data about who was receiving their program to see whether there were inequities in the way they were delivering the intervention. She noted that this work is led by Dr. Katie Hoskins.

Campbell asked whether any of the panelists’ states had Medicaid waivers to enable use of federal funds to support these programs. Hink said that a few

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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.
×

states have passed legislation to use Medicaid dollars to reimburse for violence intervention and violence intervention professionals. Her team has engaged the hospital’s policy liaisons to lobby for support and Medicaid funding. “I think we will see expansion of that in some states,” Hink said, “but we have got to get the conversation going to let people know that what is happening in [one state] can happen [anywhere].”

Campbell asked the panelists how they keep politics out of their discussions with local groups. Regan replied that “a true public health campaign is not about which [political] side you’re on, you have to be on the side of health.” She also noted that piggybacking this on Medicaid is important. Stone added that most of his organization’s advocacy work with legislators is basically begging for funds. Being a community-based organization, he said, helps with the begging process.

Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 31
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 32
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 33
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 34
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 35
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 36
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 37
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 38
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 39
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 40
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 41
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 42
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 43
Suggested Citation:"4 Barriers and Facilitators to Implementing Hospital-Based Firearm Injury Prevention Strategies in Urban and Rural Communities." 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 44
Next: 5 Collaborating with Communities to Improve Health Care System Implementation Success and Destigmatize Gun Violence Prevention »
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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