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 Skim
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3 Health Care Strategies to Reduce Firearm Injury and Mortality
3 Health Care Strategies to Reduce Firearm Injury and Mortality
Pages 15-30
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From page 15... ...
INVESTIGATING THE PIPELINE THROUGH COMMUNITY PARTNERSHIPS, INTENTIONALITY, AND COLLABORATION To start her presentation, Thea James reiterated Rivara's statement that hospital-based violence intervention programs are absolutely effective. "They really do alter the life course trajectory for victims of violence and produce healthy, stable, productive, and high-achieving citizens.
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The way the effects of redlining perpetuate today show up in the social determinants of health and health disparities, including the distribution of firearm injuries and stabbings by hospitals in the City of Boston. Boston Medical Center (BMC)
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The result, she said, is that despite having decades of experience developing models of care that address upstream drivers of health, there have been no changes in outcomes for health measures such as infant and mother mortality, diabetes mortality, deaths from cancer, incidence of depression and suicide attempts, and rates of homicides by firearms. Beginning in 2018, James and her colleagues at BMC began asking whether the role of a safety net hospital is to perpetually fill gaps or to address equity issues.
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To address this problem, her institution joined the Healthcare Anchor Network,1 whose goal is to build more inclusive and sustainable local economies through hospitals being intentional about how they hire, invest, and procure. As an example, when a hospital in Massachusetts adds onto a facility, the state requires that 5 percent of the total capital construction cost must go to the community.
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The entire effort, said James in closing, is focusing on the root causes of inequities to mitigate firearm violence and other adverse health outcomes as much as possible. THE AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA'S ISAVE INITIATIVE To begin her presentation, Rochelle Dicker explained that the American College of Surgeons Committee on Trauma is responsible for verifying and setting standards and indicators for trauma centers from level I to level IV.
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She also reiterated James's comment that without addressing the root causes of the social determinants of health, it will be difficult to greatly affect health outcomes. Dicker said: The physical environment and social determinants, along with behavioral factors, drive 80 percent of health outcomes, with 20 percent being quality related and access related, but many of us would argue that you cannot have access, really true access, without addressing the social determinants.
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. Dicker explained that it takes a community at the table as a partner to address these underlying social care needs; addressing the individual social needs goes part of the way upstream to root causes, but going all the way upstream requires strategies that address laws, policies, and regulations that create community conditions capable of supporting the health of all people.
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, poverty level (bottom middle) , and grocery store locations/food deserts (bottom right)
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Trauma-informed care, said Dicker, accounts for adverse childhood experiences and honors the fact that these exist in many violently injured patients. It also recognizes that many patients experience toxic stress resulting from prolonged, strong activation of the body's stress response system without having the counterbalance of supportive relationships to buffer that response.
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The second is to outline mechanisms by which hospitals can train, finance, and operationalize this integration. Along these lines, said Dicker, hospitals could design care delivery to integrate social care into health care, with hospital-based violence intervention programs being an example of a community-based violence intervention that engages credible messengers from the communities affected by violence as well as violence prevention professionals.
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She calls this social technology -- when all the stakeholders are at the table being listened to in a way that can lift up people and enable working upstream. THE BULLETPOINTS PROJECT BulletPoints, said Amy Barnhorst, is a firearm violence prevention curriculum project designed for health care providers.
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The nine member, multidisciplinary BulletPoints team includes emergency medicine physicians, mental health professionals, a researcher with experience researching and evaluating large public health programs, and analysts with experience in evaluation, research, public health, and public communication. The team works with other clinicians, as well as experts who have experience in areas such as public health education and firearms research.
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The Basics section, for example, goes through some of the principles for how to counsel patients at risk of firearm injury in a way that is culturally humble and takes a harm-reduction approach. It also includes information about the epidemiology of firearm violence, the people it affects, and the disparities of who it affects, as well as information about firearms themselves for clinicians who do not have expe rience with firearms, laws relating to firearms and how they may apply to patients in the mental health system, the social determinants of health, and the principles of cultural humility.
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All three speakers said that such instruments do not exist and would be difficult to develop because the risk of firearm injury and firearm death and psychological consequences of firearm violence are so individualized and varied. Responding to an audience question about how hospitals can approach violence intervention with cultural humility, Dicker said there are two things that hospitals can do.
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James agreed that trauma-informed care is extremely important because it is easy to inadvertently retraumatize people when a clinician does not understand that some of their behavior is a manifestation of trauma. When Barnhorst was asked whether the BulletPoints Project was willing to share its curriculum with other hospitals, she answered, "absolutely yes." All of the content is available online with the goal that others borrow and use it.
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