A Regional Approach to Hospital-Based Violence Intervention Programs Through LOV

Abstract

Context:

Community violence is an underaddressed public health threat. Hospital-based violence intervention programs (HVIPs) have been used to address the root causes of violence and prevent reinjury.

Objective:

In this article, we describe the methodology of the St Louis Region-wide HVIP, Life Outside Violence (LOV) program, and provide preliminary process outcomes.

Design:

Life Outside Violence mentors intervene following a violent injury to decrease risk of subsequent victimization and achieve goals unique to each participant by providing therapeutic counseling and case management services to patients and their families.

Participants and Setting:

Eligible patients are victims of violent injury between the ages of 8 and 24 years, who are residents of St Louis, Missouri, and present for care at a LOV partner adult or pediatric level I trauma hospital.

Intervention:

Enrolled participants receive program services for 6 to 12 months and complete an individual treatment plan.

Main Outcome Measures:

In this article, we report LOV operational methodology, as well as process metrics, including program enrollment, graduation, and qualitative data on program implementation.

Results:

From August 15, 2018, through April 30, 2022, 1750 LOV-eligible violently injured patients presented to a partner hospital, 349 were approached for program enrollment, and 206 consented to enroll in the program. During this pilot phase, 91 participants graduated from the LOV program and have process output data available for analysis.

Conclusions:

Life Outside Violence has been implemented into clinical practice as the first HVIP to influence across an entire region through partnership with multiple university and hospital systems. It is our hope that methods shared in this article will serve as a primer for organizations hoping to implement and expand HVIPs to interrupt community violence at the regional level.

Context

Community-based violence is a public health threat in the United States. Violence is a top 3 cause of death for those aged 1 to 44 years, with firearm injuries as the leading cause of death in youths aged 0 to 24 years and Black males aged 15 to 34 years—resulting in more than 45 000 deaths in 2020.^1,2 In addition, in 2019, there were nearly 1.4 million (1 351 000) emergency department (ED) visits for assault-related injuries—an increase of nearly 200 000 visits from 2018.^3,4 St Louis, Missouri, is at the center of the firearm epidemic.^5–7 Between 2015 and 2019, the average rate of firearm-related assaults was 768.5 per 100 000. There were 1226 homicides during this time, an average annual per capita rate of 63.1 per 100 000.⁵ This represents one of the highest homicide rates in the United States.

Violently injured patients may feel that few alternatives are available other than retaliation or violent retribution. In addition, once physically well, they have a high likelihood of returning to the same behaviors and external conditions that may have contributed to their violent injury in the first place.⁸ As a result, violently injured patients are at high risk of reinjury or to perpetrate violence themselves in acts of retaliation.⁹ Rates of subsequent victimization are as high as 77% among penetrating trauma patients (firearm injuries and stabbings), and the likelihood of death increases with each ED visit.^10–12 Black, Indigenous, and people of color disproportionally experience violent injury inequities due to structural racism and discrimination.^13–15 Survivors experience long-term sequelae such as posttraumatic stress disorder, attempted suicide, and substance use disorders.^16,17

Hospitals are the primary location where patients who have suffered a violent injury seek medical care and thus are uniquely positioned to interrupt the cycle of violence for high-risk individuals.¹⁸ Hospital-based violence intervention programs (HVIPs) have been used in concert with broad multidisciplinary strategies to address the root causes of community-based violence and prevent reinjury. A review of the ability of adult HVIPs to prevent reinjury long-term ranged from no effect (4 studies) to positive effect (3 studies), indicating that rigorous evaluation methods are needed to further investigate HVIP efficacy and implementation strategies.¹⁹ Some research suggests that HVIPs produce cost savings for hospitals both by decreasing subsequent victimization and the need for associated costly treatments, as well as through an ultimate reduction in violent injury and death, and the associated toll on communities.^20–23 However, further study on the efficacy of these programs is required.

In response to endemic community-based violence, leaders and stakeholders across Washington University in St Louis (WUSTL), St Louis University, and their 4 associated adult (2) and pediatric (2) level I trauma hospitals representing 2 health systems came together to develop and implement the St Louis region-wide HVIP, Life Outside Violence (LOV). These universities and hospitals care for the majority of victims of violent injury in the region.

In this practice report, we describe the LOV program and its preliminary process outcomes. The LOV program is the first to attempt to influence reinjury across an entire region; traditionally, HVIP outcomes and reinjury measurements are limited to each program’s individual institution. Data sharing across hospital systems in our region is uncommon. Our program contributes to a growing body of literature highlighting the need for cross-sector data sharing to support violence reduction.^24,25 It is our hope that the methods described in this article will guide organizations hoping to implement and expand HVIPs to a multisystem level that is better able to interrupt regional community violence.

Methods

The LOV’s mission is to promote positive alternatives to violence in order to reduce the incidence of retaliation, criminal involvement, reinjury, and death among individuals affected by violence.²⁶ Table 1 describes our program’s logic model. Methods and results presented herein are from the LOV program’s pilot period from August 2018 through April 2022.

TABLE 1.

Hospital-Based Violence Intervention Program Logic Model

	Activities		Outputs		Results Long–Term (Impact): 5 y
Resources Inputs	Activities	Participants	Immediate: 24 h to 2 wk	Medium Term (Outcomes): 6 mo to 1 y
What we invest	What we do:	Who we reach:	How we do it:	Resultisi over time:	Ultimate impact(s):
Dedicated LOV working group representing all partner hospitals and universities Support from executive leadership of all partner hospitals and universities Data sharing and use agreement for evaluation Program design and implementation plan Program materials (eg, enrollment forms, progress tracking forms, etc) Program evaluation plan Program staff (mentors and coordinator) and training/orientation process Program funding	Connect with patient as soon as possible after violent injury Assess at bedside or at agreed location Provide intervention from “menu of interventions”	Violently injured patients Family members and friends	Diffuse crisis Enrollment in the LOV program Initial connection with program mentor Develop individual treatment plan Link to services, (eg, medical, psychological, housing, educational)	Patients make progress in addressing their individual risk and protective factors for violence Family members make progress Link to additional needed services, (eg, medical, psychological, housing, educational) Lower reinjury rates	Lower reinjury rates Lower arrests Improved sense of well-being Increase in protective factors (eg, employment, high school, etc) Decrease in risk factors (eg, criminal activity, substance use/abuse)

Abbreviation: LOV, Life Outside Violence.

Eligibility

The LOV mentors intervene following a violent injury to decrease risk of subsequent victimization and support goals unique to each participant by providing therapeutic counseling and case management services to patients and their families. Mentoring and behavior modeling are most effective during childhood, through adolescence, and on to early adulthood.²⁷ For this reason, coupled with high rates of violent injuries among young people, LOV’s pilot phase eligibility criteria included victims of violent injury (blunt assault, stabbing, and firearm injury), aged 8 to 24 years, who were residents of St Louis City and St Louis County, and presented for (received) care at a LOV partner trauma hospital ED or trauma ward. As more than 99% of victims of violence presenting to LOV partner hospitals in St Louis are English-speaking non-Hispanic, which reflects our regional composition, only English-speaking patients were enrolled in this program.²⁸ The LOV enrollment excluded individuals who presented after a failed suicide attempt, intimate partner violence, and those with significant cognitive impairment (ie, severe traumatic brain injury), as their medical and psychiatric needs are different from those addressed in this program.

Data tracking

To identify the regional burden of violent injury and evaluate LOV program outcomes, we created a regional St Louis HVIP Data Repository (STL-HVIP-DR). This repository, which is described elsewhere, houses longitudinal data on all adult and pediatric patients who presented to 1 of the 4 LOV partner hospitals with a violent injury from 2010 to present.²⁹ It contains demographic characteristics (eg, age, sex, gender, race, ethnicity, residential address), treatments (eg, hospital disposition, operations, clinic visits), and clinical outcomes (eg, violent reinjury, readmissions) among violently injured patients. All programmatic and outcome data tracking related to the LOV program, and sharing among LOV-partner institutions, is supported by the STL-HVIP-DR Data Use and Sharing Agreement and the WUSTL Institutional Review Board. Participant data are recorded by LOV mentors and stored in REDCap version 7. This program has been approved by the WUSTL Institutional Review Board (no. 202203068).²⁹

Key personnel

The LOV program operations include many key personnel and advisory committees, who are described in Table 2.

TABLE 2.

Life Outside Violence Key Personnel and Advisory Committees

Program manager (n = 1)	Responsible for successful implementation and daily operation of the LOV program, including training and supervision of mentors who provide direct practice, coordination of multiple committees of key stakeholders, and delivery of data-driven research and funding outcomes.
Mentors (n = 5)	Responsible for enrollment, case management, and therapeutic behavioral health interventions to patients and their families. Provision of these services occurs in the community (home, school, etc) and posthospital discharge. Each hospital site has 1 dedicated program mentor (n = 4) and a floater mentor (n = 1) was hired centrally with an agreement between the hospitals for privileges to see patients at all 4 hospital sites. The floater mentor rotates between hospital sites as volume dictates. Each mentor can carry 20 active patients effectively at any given time.
Program data management team (n = 4)	Led by WUSTL Institute for Public Health Data Managers, who are responsible for compiling and managing the STL-HVIP-DR and all LOV program data.
Data review and approval committee (DRAC) (n = 12)	Representatives from each partner hospital and university who determine the appropriate use of the data in the STL-HVIP-DR and approve publications and reporting of research using these data, as described in the STL-HVIP Data Use and Sharing Agreement.29
Operational steering committee (n = 15)	Representatives from each partner hospital and university who guide shared decision-making to advance the mission of the LOV senior executive steering committee. This committee offers general guidance related to LOV implementation and coordination, quality improvement, evaluation, training, and communication. It also serves as the liaison between LOV and each institution’s senior leadership staff. Some committee members are also members of the DRAC.
Senior executive steering committee (n = 6)	Hospital and university executives who provide senior leadership supportfor LOV’s mission and program operations at each hospital site and foster cross-university system collaboration.

Abbreviations: LOV, Life Outside Violence; STL-HVIP-DR, St. Louis HVIP Data Repository; WUSTL, Washington University in St Louis.

Recruitment, consent, and enrollment

On arrival to the ED or inpatient trauma service, hospital providers (such as physicians, nurses, injury prevention coordinators, or social workers) identify patients who are eligible for LOV enrollment. Providers at each hospital review the program with patients and their families and provide written material about the program. Providers then contact the LOV mentors via telephone, electronic message, and through automated alerts to inform them that a LOV-eligible victim of violence has presented for care at the hospital.

All eligible patients are informed that a LOV program mentor will contact them within the next few days. If the patient is admitted to the hospital and clinically stable, the mentor may visit the patient in his or her hospital room. If the patient is discharged from the hospital before the mentor can make initial contact, the mentor will make contact by phone or visit patients and their families in the community. During an initial engagement period, the patient is asked whether he or she would like to participate in LOV. If the patient agrees, they sign a consent form to enroll in the program. A parent or a guardian must provide consent for patients younger than 18 years. The enrollment process includes an initial intake assessment. The LOV-enrolled participant and program mentor (and guardian, if desired) schedule regular meetings to be held at a mutually agreed upon location.

Service provision and mentor intervention

Over the course of meetings with the LOV-enrolled participant, the mentor employs a combination of evidence-based strategies to help patients develop and make progress on an individual treatment plan (ITP).³⁰ Frequently used strategies are outlined in Table 3 and include a combination of the following:

TABLE 3.

Evidence-Based Strategies Used to Progress the Individual Treatment Plan

Brief intervention	This is a service model based on stage-based motivational and cognitive behavioral approaches.31–33 It involves the use of motivational interviewing and cognitive behavioral approaches to increase insight and learn skills to improve health and social functioning. It can be tailored for a variety of populations or settings and can be used as a stand-alone treatment for those at risk as well as a vehicle for engaging those in need of more extensive levels of care.
Mentor-implemented violence prevention	A violence prevention approach in which mentor and participant meet at least 6 times over a 2- to 6-month period.34 Meetings are guided by a workbook grounded in social-cognitive theory and include sessions on conflict management and “hot buttons,” problem solving, weapon safety, decision making, goal setting, role-playing scenarios, and a pledge to remain nonviolent.
Trauma-informed treatment	Mentors provide trauma-informed care for the participant. This is informed by a framework ground in, and directed by, an understanding of the neurological, biological, psychological, and social effects of trauma and violence on humans.35 Mentors are responsive to the prevalence of trauma in persons and engage in practices that avoid retraumatization. Key principles include safety, trustworthiness, choice, collaboration, and empowerment.
Case management	A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes and reduce ED visits.36 Case managers provide crisis counseling and conduct needs- and strength-based assessments and risk assessments.

Abbreviation: ED, emergency department.

Ongoing follow-up during program and ITP

The initial risk and needs assessment provide the mentors with much of the information they need to determine what services the participant needs in the immediate-, short-, and long term. The length of time that patients remain in the program (duration) and the intensity of intervention and services provided (dosage) vary depending on patient-specific needs. Hospital-based violence intervention programs generally begin to see participant progress within 6 months to a year on at least 1 area identified in the patient ITP.^34,37 Broad ITP goal categories include health and health care (eg, physical health, mental health), economic stability (eg, employment, financial literacy), education (eg, academic engagement and achievement, vocational training), social and community context (eg, family and peer relationships, school sport, offspring well-being), neighborhood and built environment (eg, housing, transportation), and other basic needs (eg, food security, government-issued licensure).

Mentors adjust the duration and dosage of services over time as the participant completes each step or new information is uncovered as a part of participant ITP. Many participants will have more than 1 area of emphasis in their treatment plan. For example, participants at high risk of subsequent victimization or retaliation may require the most intensive services the program can offer. Staff work with them more frequently and for a longer period than those at lower risk. Participants with low to medium risk, but with substantial needs for a variety of services, such as mental health counseling and educational advocacy, may require moderate to intensive services over a 6-month period, which can then be reduced on the basis of reassessment and progress.

Small incentive items and family emergency assistance are offered to help retain and motivate enrolled participants and to assist with emergencies. Incentives include items such as transportation (eg, ride share, metro pass), job preparedness (eg, new clothes or work uniform), and educational expenses (eg, books, online application fees). Emergency assistance may include funds to help with household expenses such as moving, beds, short-term housing, utilities, and so forth.

Participant movement through the program

After enrollment in LOV, the ITP is developed collaboratively between the participant and the mentor (and the guardian if the participant is younger than 18 years). The mentor begins meeting at intervals determined by the needs of each participant. Consistent meetings are required to be considered an “active” participant in LOV. If the participants go 60 days without contact, they are considered “inactive” and are sent a letter stating that unless they schedule a meeting within 30 days they will be discharged as “lost to follow up.” Progress is made using therapeutic interventions and mentoring as the participants and their family work toward meeting the goals of the ITP. Most participants are active in the program for 6 to 12 months. The program intervention is complete when either (a) all ITP goals are met, or (b) a minimum of 6 months of active engagement with follow-up assessments are completed, even if all goals are not met. This graduation determination is made on the individual level between the participant and the mentor. After intervention completion, the participant is discharged as a “graduate” and sent a congratulatory letter.

Program outcomes and evaluation

The primary outcome of this program is to reduce recurrent violent injury among participants. Secondary program outcomes assess risk factors for violence and protective factors against violence among victims of violence. During the program, the participants complete assessments with their mentors to meet the following objectives described in Table 4.

TABLE 4.

Life Outside Violence Participant Enrollment and Assessment Timeline

By enrollment and at intermediate time points prior to discharge	Participants complete intervention assessments on key domains related to physical, behavioral, and mental well-being, as well as risk and protective factors related to violence.
By the end of week 4 after enrollment	Participants identify goals for their ITP with their mentor. Participants are screened by a licensed clinical provider to assess for underlying behavioral/mental health issues.
By discharge from the program	Participants are referred to an appropriate medical/behavioral/mental health provider as needed. Participants are measured on key domains related to physical, behavioral, and mental well-being, as well as risk and protective factors related to violence.

Abbreviation: ITP, individual treatment plan.

Secondary measures of program success, as coded from completed participant ITPs, include outputs such as academic success, securing or sustaining employment, decreased risk-taking behavior and criminal involvement, positive leisure and recreational activity, positive social support system and connectivity, and improved physical and mental health care.

Alignment with regional and national efforts

The St Louis Area Violence Prevention Commission advocates for coordinated, well-resourced policies, support systems, and interventions among area governments, institutions, and agencies that serve individuals and families at risk for violent crime. The LOV stakeholders are members of the St Louis Area Violence Prevention Commission, which was developed in conjunction with the LOV program.³⁸ Life Outside Violence was developed with guidance from the Health Alliance for Violence Intervention and is a current member program.³⁹ The Health Alliance for Violence Intervention is a national organization that fosters hospital and community collaborations to advance equitable, trauma-informed care and violence intervention and prevention programs.

Evaluating factors impacting program implementation

The LOV pilot phase implementation included qualitative interviews and focus groups of a purposive sample of 3 groups of 41 program stakeholders to evaluate factors impacting implementation. (1) LOV mentors (n = 6) participated in 5 focus groups and 1 personal interview designed to explore the factors that impacted their practice in the areas of recruitment, engagement, assessment, treatment, and discharge; (2) a multidisciplinary sample of program administrators, data managers, social work supervisors, and physicians (n = 14) across the LOV partner hospitals and universities participated in semistructured personal interviews. Interviews focused on factors impacting program development, promotion, sustainability, operations, implementation, and evaluation; (3) a convenience sample (n = 21) of LOV participants actively enrolled in the program for at least 6 months participated in qualitative telephone interviews. Interviews focused on participant perspectives of service quality, mentor characteristics, and areas of program improvement.

Study team member M.M. conducted 75% of the interviews and V.M. conducted 25%. Interviewers used member checking within interviews to verify information by routinely checking for accuracy of information within the interview and then asking participants to clarify their comments as needed. Interviews transcripts were analyzed using thematic analysis.^40,41 M.M., V.M., and K.M. blended codebook and reflexive thematic analysis methods by developing a preliminary codebook to guide initial coding and then used reflexive thematic analysis to confirm codes and generate general themes and subthemes across the interviews.^40,41

The analysis process consisted of several steps. First, after reading interviews several times, V.M. and K.M. independently coded approximately 85% of individual and group interviews, and M.M. coded all interviews. Second, the team met several times to confirm and revise codes as needed and to generate initial categories and subcategories. Memo-notes, peer debriefing, and audit trails were used to check codes, record, and document interpretations and analytic decisions.^42,43 Third, initial categories and subcategories were then checked and refined within and across the collected data and with the initial research questions and existing literature to generate a final set of themes and subthemes that could be used by researchers and clinical staff to guide implementation efforts for future HVIP programs.^40,44,45

Sample case study (fictious for patient confidentiality)

J.S.is a 19-year-old Black youth living with his mother in St Louis, Missouri. On January 1, 2019, he was shot in the arm when walking in his neighborhood and taken to a LOV-partner adult level I trauma hospital ED. He received medical care for his injuries in the ED, which included a broken left wrist. Prior to discharge, the ED social worker collected phone numbers for his emergency contacts, provided him with a handout about the LOV program, and informed him that he would be contacted by the LOV mentor team.

On January 3, a LOV program mentor called J.S., who did not answer. His voice mail box was not set up. The mentor then called J.S.’s mother, who was able to put her in touch with J.S. The LOV mentor met with J.S. and his mother at a local library on January 10. At that time, J.S. consented to LOV program enrollment. Program consent paperwork was completed at that visit. Over the next 3 weeks, J.S. worked with his LOV mentor to complete his ITP. He identified goals to complete his general education development, secure employment, and get his own place to live.

His LOV mentor provided case management services and trauma-informed treatment by helping J.S. schedule his orthopedic surgery follow-up appointment through a different LOV-partner hospital system at J.S.’s mother’s request, as that was where he received all his pediatric care. The LOV mentor also arranged transportation to this and subsequent appointments with a local rid-share program. In addition, J.S. told his LOV mentor that the heat was turned off at his house. The LOV mentor arranged use of program emergency assistance funds to have the heat turned back on.

From mid-January through the end of February, J.S. met with his LOV mentor weekly, with intermittent texting, to work on his ITP. During this time, J.S. endorsed poor sleep, increased feelings of anxiety, and having a short temper after his injury. His mentor recognized signs of posttraumatic stress disorder. The LOV mentor provided a brief intervention using motivational interviewing and cognitive behavioral therapy to help J.S. manage these symptoms and helped him schedule an appointment with a psychiatrist for March.

In March, after J.S. had physically recovered from his injury, his LOV mentor began a mentor-implemented violence prevention coaching every other week for the next 6 months. In July, J.S. completed his general education development and was able to enroll in a job corps training program. By August, J.S. was busy and doing well in this training program, sleeping better, and had a better handle on the impulse control and anger issues that started after his injury. He and his mentor agreed to change their meeting schedule to monthly in person, with weekly check in phone calls and texts. J.S. was very excited when his LOV mentor attended the job-training program graduation ceremony.

By the end of November, J.S. had been in his new job for more than a month. His LOV mentor helped him find an apartment and furnishings (case management). In December, J.S. and his LOV mentor reviewed his ITP and progress through the LOV program. Both agreed that J.S. had accomplished his personal goals and additionally had avoided a violent reinjury for the entire year of LOV participation. J.S. then graduated from the program and received a congratulatory letter for program completion. Since program graduation, J.S. and his LOV mentor still text and catch up in person from time to time.

Results

Later, we report patient-level descriptive statistics and process outputs from the LOV program’s pilot phase from August 2018 through April 2022. A detailed analysis of LOV participant outcomes is outside the scope of this practice report and will be reported separately.

Enrollment

From August 15, 2018, through April 30, 2022, 1750 eligible violently injured patients presented to a LOV partner hospital and should have been contacted with information about the program. Contacts occurred in person, via telephone, electronic message, and mailed letter. Of these LOV-eligible patients, 349 have 1 or more contact dates recorded in REDCap by LOV mentors confirming that they provided information about LOV (20%). These 349 patients received an average of 2.3 contacts prior to enrollment in the program. Of these, 206 consented to enrollment (59%). Demographics of patients who were contacted for LOV enrollment and program participants are described in Table 3. Because of institutional review compliance guidelines, we were not able to collect demographic or clinical information on patients who declined participation in LOV.

Program graduates

During LOV’s pilot phase, 91 participants graduated from the LOV program and have complete data available for analysis. Process metrics (Table 3) include the number of times graduates were contacted by LOV mentors regarding program enrollment, how long program graduates were enrolled in LOV, details on the frequency of visits with mentors, and mentor progress note documentation (Table 5).

TABLE 5.

Descriptive Statistics of Life Outside Violence Program-Contacted Patients, Enrolled Patients, and Program Graduates

	Contacted n = 349	Enrolled n = 206	Graduated n = 91
Age, mean (SD), y	19.0 (3.6)	18.4 (3.8)	18.6 (4.2)
Racial group
White	10 (2.9%)	3 (1.5%)	2 (2.2%)
Black	328 (94.0%)	197 (95.6%)	86 (94.5%)
Multiple race	1 (0.3%)	0 (0.0%)	0 (0.0%)
Unknown	10 (2.9%)	6 (2.9%)	3 (3.3%)
Sex
Male	235 (67.3%)	134 (65.0%)	57 (62.6%)
Female	111 (31.8%)	72 (35.0%)	34 (37.4%)
Unknown	3 (0.9%)	0 (0.0%)	0 (0.0%)
Ethnicity
Hispanic	4 (1.1%)	4 (1.9%)	2 (2.2%)
Non-Hispanic	158 (45.3%)	158 (76.7%)	82 (90.1%)
Other/do not know	2 (0.6%)	2 (1.0%)	1 (1.1%)
Missing	185 (53.0%)	42 (20.4%)	6 (6.6%)
Documented provider referral	68 (19.5%)	68 (33.0%)	40 (44.0%)
Documented ITP goal	Notapplicable	173 (84.0%)	91 (100.0%
Pre-enrollment contacts, mean (SD)	2.6 (2.4)	2.3 (1.7)	2.5 (2.0)
Days enrolled, mean (SD)	Notapplicable	274.5 (135.0)	375.6 (88.5)
Postenrollment visits, mean (SD)	Not applicable	8.5 (3.2)	11.1 (2.0)
Progress notes, mean (SD)	Notapplicable	24.3 (19.0)	37.4 (16.7)

Abbreviation: ITP, individual treatment plan.

Qualitative data on program implementation

Thematic analysis of stakeholder interviews generated several themes relevant to LOV implementation.⁴⁶ These finding have recently been corroborated (Mancini, unpublished data, March 4, 2022). Themes were organized across 2 broad domains: service provision characteristics, and organizational structures and processes.

Service provision characteristics included themes such as the importance of integrating behavioral health and primary care services with a multidisciplinary and collaborative team environment. A second theme in this domain was the importance of hiring credible and experienced service providers who can serve as mentors but who are also capable of providing case management and clinical therapy services. Finally, effective engagement and retention of participants in the LOV program were predicated on maintaining extended contact with participants and their families and deploying a range of recruitment efforts with eligible individuals over time (eg, visits, community meetings, phone calls).

Important organizational structures and processes relevant to the effective establishment, operation, and sustainment of LOV included (1) making community interventions for violence, such as LOV, a standard of care, and deploying ongoing professional training about the program to develop champions and educate staff on the importance of the program; (2) developing multidisciplinary networks of hospital, university, and community partners to provide health care, organize funding and evaluation, and provide community services; (3) establishing and deploying a strong evaluation team across the hospital sites to share data, improve the quality of services in real time, and demonstrate program effectiveness to hospital and community partners; and (4) establishing robust patient recruitment and enrollment pathways that efficiently and effectively identify, track, and engage potential enrollees over time.

DISCUSSION

Life Outside Violence has been implemented into clinical practice. It is the first HVIP to span an entire region through partnership with multiple university and hospital systems. Through LOV program planning and implementation, we have developed networks with key violence prevention stakeholders across disciplines in our partner universities and hospitals and with regional and national stakeholder organizations. This allowed us to develop and sustain the infrastructure needed to implement LOV at the regional level, such as a multisystem data use and sharing agreement, the STL-HVIP-DR, and several committees to oversee program and data stewardship. Through this process, mentors at each hospital site use the same data entry system (REDCap) to provide program services to the LOV victims of violence. Our preliminary analyses are able to report patient demographics, process outputs, and themes associated with program implementation.

Next steps, limitations, and opportunities

As we move into the next phases of the LOV program, additional studies are planned to continue evaluating program implementation, process, and outcomes. A region-wide evaluation of the impact of LOV on the violent reinjury rate among participants is forthcoming. We will also delve into secondary measures of program success through qualitative evaluation of participant goals, (eg, academic success, employment, behavior change), provision and receipt of case management services, and referrals to physical and mental health care.

During the pilot phase, we found variability in mentor documentation surrounding timing of visits and assessment of each participant’s ITP goals. As we move forward, tracking of these process metrics will be facilitated and enhanced by data entry standardization updates in REDCap and a new secure, internal, Web-based, interactive dashboard to visualize and track program metrics.

As with many new programs, during LOV’s pilot phase we encountered challenges contacting and enrolling eligible patients into the program. At this time, it is unknown why mentors had documented contact with only 20% of eligible patients. Other HVIPs have cited challenges of recruiting participants due to logistical challenges such as contacting patients (frequent changes of address and phone number) and lack of adequate research personnel to engage study participants.^19,23,47 We speculate that our low contact rate during the pilot period was related to (a) the high volume of LOV-eligible patients (n = 1750) relative to the small number of LOV program mentors (n = 5) conducting patient outreach while also providing clinical services, (b) unstable contact information and phone access among participants, and (c) common pilot program implementation barriers regarding building program awareness across 2 health systems EDs, intensive care units, hospital inpatient wards, and clinics—especially after the onset of the COVID-19 pandemic and associated medical staff turnover. Upcoming studies will further delve into this high-need area to specifically evaluate barriers and facilitators to LOV program recruitment and enrollment.

To improve the frequency of documented contact with eligible patients, we recently hired 4 community outreach representatives. The community outreach representatives are staff who share lived experience with the victims of violence we are attempting to reach, including previous violent victimization, living and working in the same neighborhoods, and involvement in the criminal justice system. They may have increased ability to foster relationships needed to connect with victims of violence to increase program enrollment.

We also plan to work with the Health Alliance for Violence Intervention to help standardize definitions and tracking of data across programs surrounding acute injuries (eg, how acute and recurrent firearm injuries are coded and calculated), program contact rates (how often eligible patients are notified about the program), and program enrollment rates (how often eligible patients consent to program participation).

Finally, to improve availability of services to a larger at-risk patient population, in 2022, we began offering the LOV program to an expanded age range of patients (now up to patients 30 years of age) and residents of Illinois, who comprise part of our LOV-partner hospital bistate patient catchment area.

Conclusions

The program methods, outputs, and infrastructure described herein will support robust LOV programmatic outcome evaluations in the future. It is our hope that methods shared in this article will serve as a primer for organizations hoping to implement and expand HVIPs to interrupt community violence at the local, regional, and national levels.

Implications for Policy & Practice.

• Community violence is a pervasive and underaddress public health threat.

• Hospital-based violence intervention programs (HVIPs) have been used in concert with broad multidisciplinary strategies to address the root cause of community-based violence and prevent reinjury.

• In response to endemic community-based violence, stakeholders across 2 research universities and their 4 associated adult and pediatric level I trauma hospitals representing 2 health systems came together to develop and implement the St Louis region-wide HVIP, Life Outside Violence (LOV).

• In this practice report, we describe the LOV program and its preliminary process outcomes. The LOV program is the first to attempt to influence reinjury across an entire region; traditionally, HVIP outcomes and reinjury measurements are limited to each program’s individual institution.

• The program methods, outputs, and infrastructure described in this article will support robust LOV programmatic outcome evaluations.

• Our program contributes to a growing body of literature highlighting the need for cross-sector data sharing to support violence reduction. It is our hope that methods shared in this article will serve as a primer for organizations hoping to implement and expand HVIPs to interrupt community violence at the local, regional, and national levels.