Ask David Ross to describe an average day on the job. He says it doesn’t exist.
Ross is a violence intervention specialist at the University of Maryland Medical Center in Baltimore. Although he isn’t a doctor, he has been working at the hospital as part of its violence prevention program for close to 10 years. His team works with patients who are victims of violence — stabbings, shootings or beatings — and whom physicians flag as candidates for the program’s assistance.
His challenge is to figure out the factors in their lives that put them at risk of violence.The work is time-consuming, and the relationships he builds with these patients can last months and even years.
Do you feel safe at home? Do you have health insurance? A high school diploma? A stable job? Having health insurance or a diploma is no guarantee against violence, but Ross and his colleagues ask such questions to help the team connect patients with programs that might improve their lives and insulate them from the violence that put them in the hospital.
“Some days, it can be emotional. Or it can be gratifying,” Ross said. “I spoke to a patient the other day, and he almost had me crying.”
Sometimes that kind of emotion comes from the devastating things patients have seen, whether it’s the result of a dysfunctional living situation, substance abuse, poverty or other social ills. Other times, it’s because “you thought you made progress — and then there’s a setback.”
Maryland is a pioneer in this type of coordinated effort, having launched its anti-violence program in 1998. Now, about 30 hospitals across the country have developed similar initiatives. They follow Maryland’s “wraparound” approach, which involves following up with patients after they leave the hospital and providing medical and social support to keep them out of harm’s way — by, for example, getting them into drug rehab or education classes for people who have not finished high school. The hospitals are acting on the notion that keeping violent injury from recurring will ultimately reduce their expenses and improve people’s long-term health. In other words, they increasingly view violence prevention as both good medicine and good business.
On this particular day, Ross visited seven patients who were being treated for violent injuries. Ross’s job isn’t just to identify the trouble spots in a patient’s life; it also involves moving with the person through the legal and medical systems, sometimes acting as an advocate.
The day before, for instance, he had accompanied a mentally ill client to court to make sure the man’s condition was understood by authorities.
On such days he dresses in a suit instead of his hospital uniform: pink scrubs, an outfit that shows that although he doesn’t stitch wounds or prescribe pills, he’s part of a team dedicated to keeping patients healthy.
As experts increasingly view violence as a medical concern, hospitals see an opportunity to prevent it.
“There’s been a groundswell of professionals understanding that this is a public health issue,” said trauma surgeon Rochelle Dicker, a professor at the University of California at San Francisco who also directs the UCSF Medical Center’s violence prevention program.
The 2010 federal health law supports that interest. It says nonprofit hospitals have to work harder if they want to maintain their tax-exempt status. Among other requirements, they must formally measure their surrounding community’s health needs at least every three years and implement a strategy to address them.
To this end, a growing number of hospitals, especially those located in areas with high rates of violent crime, are partnering with local organizations to try to reduce neighborhood violence, said Jonathan Purtle, an assistant professor at Drexel University who researches hospitals and violence prevention.
The Department of Justice has been supportive, too. In a 2012 report, it recommended that hospitals become more involved in violence prevention, through counseling patients directly or connecting them to education, gang diversion programs, substance abuse treatment and other social services.
Research shows that if hospital patients with gunshot or stab wounds return to their previous circumstances, the odds are good that they will come back to the emergency department with another injury.
In addition, trends and anecdotal evidence suggest that people at higher risk for violent injury are likely to face issues such as domestic violence, mental illness and substance abuse. They also often deal with other stressors, such as poverty and bad housing.
These challenges can result in health problems, including lead poisoning and poor nutrition, which the hospital can work to address. Even if they can’t change, for instance, a neighborhood’s crime rate or drug culture, they can help someone get into rehab or find somewhere new to live.
Much of the growth in hospital interventions has happened in the past five years, Dicker said.
“It’s becoming a more established understanding that this kind of violence is preventable,” said Rebecca Cunningham, an emergency medicine professor at the University of Michigan who directs its injury center and is the associate director of its youth violence prevention center. “And we can have programs that can prevent it, and the hospital and emergency department are really critical locations for this.”
Michigan’s center doesn’t do the same level of outreach and case management as Maryland’s. Hospital patients between the ages of 14 and 20 and from neighborhoods where violence is more prevalent are approached for a counseling session — what Cunningham called a “preventive” intervention.
So far, there isn’t much research measuring such programs’ effectiveness. But the findings that are available show promise.
UCSF found that people who had come to the hospital with a gunshot or stab wound and then participated in the intervention program were far less likely to get injured again. The number of patients returning with another violent injury dropped from 16 percent to 4.5 percent.
And in a paper published last year, researchers estimated that the program would save the hospital half a million dollars annually.
That’s crucial. “It’s very important to be able to talk about cost-effectiveness” as hospitals look to curb expenses, Dicker said.
The University of Maryland’s statistics are similarly encouraging. Research found that victims of violent injury who went through the program were 83 percent less likely to return because of another violent event compared with those who didn’t participate, said Tara Reed Carlson, who directs the university’s Center for Injury Prevention and Policy. Those who had participated in the program were more likely to have a job and less likely to be involved in criminal activity.
Ross said the work he does and the change he sees underscore the value of intensive outreach. The before-and-after contrast is striking. “I’m talking about young guys who haven’t had any guidance,” he said. “That’s rewarding.”
Often, he said, patients stop by to visit, years after they have gone through the program. They share new successes such as buying a home or getting married.
“It makes you feel good,” he said. “You’re doing something that’s needed.”
This article was produced through a collaboration between The Post and Kaiser Health News, an editorially independent news service that is a program of the Kaiser Family Foundation.