Violence is a serious public health problem with over 2 million injuries annually requiring medical attention leading to nearly 50,000 deaths. This comes at an enormous financial cost to the US healthcare system. In 2000, total costs associated with nonfatal injuries and deaths exceeded $70 billion with 92% of this cost due to lost productivity. $5.6 billion was spent on medical care. The burden of violence persists beyond discharge from the hospital. Victims of violence carry cumulative load, with higher incidence of alcohol and drug use, and mental disorders following injury. Half of patients injured by violence will be reinjured. The devastation of violent injury extends beyond patients and families; it is seen in the providers who care for these patients. Approximately 57% of ER physicians and surgeons report symptoms of burnout.
Wicked Problem Description:
A Wicked Problem looms over this nation; it knows no boundaries, touches all ages and devastates those it afflicts. That Wicked Problem is violence. Omaha, Nebraska is ranked #25 as best places to live and most affordable cities by U.S. News. Given these statistics, some may disregard Omaha as a violent town given its Midwest values and small town feel. However, data from the trauma registry at Nebraska Medicine (NM) paints a much different picture. In 2016, NM treated 146 patients with gunshot wounds, stab wounds and assault. 34% of those injured were between the ages of 18-28 and 86% were male. 83% of injuries occurred in North or South Omaha, where up to half of the population is African American, and unemployment rates range between 20-30% (2010 U.S. Census).
In 2011, the Violence Policy Center of Washington, D.C. reported Nebraska as the deadliest state for African-Americans with a black homicide rate of 34.4 per 100,000 people. There are an estimated 80 gang cliques in Omaha with over 2,600 members. In 2016, the city endured 35 homicides. Nebraska does offer the good life for some, but not all. Violence infiltrates and disrupts the lives of many in Omaha. While the violence may be more prominent in North and South Omaha, this is a whole community issue and should be tackled as such.
Dusk to Dawn (D2D) is a 3-hour program built on an evidence based anti-gang curriculum, the “Phoenix Curriculum”. D2D begins with participants reliving the story of a 20 year old named Roberto, killed by violence in the very trauma bay where he died. The students hear the story of his arrival, care, and death in the hospital. They then undergo a set curriculum in violence prevention led by Stewart Giddings, the Operations Director at YouTurn . The “Phoenix Curriculum” focuses on goal setting, problem solving, and identifying and negotiating risk/protective factors.
Through the RWJF Clinical Scholars program, we plan to expand D2D and create a hospital-based violence intervention program (HBVIP). In Year 1, we will expand D2D to include students within the Omaha Public Schools and youth detention system. We plan to develop a referral process that screens to identify the most at-risk youth within these two organizations.
In Year 2, we will teach a longer 25-hour/8-week version of the “Phoenix Curriculum” to those youth identified at highest risk. To increase the number of youth touched by this program, we will use the “Train the Teacher” approach. Our trained D2D leaders will teach instructors within the Omaha Public Schools and youth detention centers to offer the same curriculum. We will adapt the “Phoenix Curriculum” and our teachings to meet the needs of the individual organizations with the support and guidance of our community partners. We also recognize that violence is often rooted in families so youth prevention must involve parents. Jennifer Burt, PhD, LP will lead parenting groups prior to the 25-hour course. She will share lesson plans with the parents, recommendations for supporting their child in the program, and provide a wrap-up session once the program is completed.
In Year 3, we will build a HBVIP at NM. The groundwork begins in Year 2 with a needs analysis and strategic plan to be presented to NM leadership and administration. Working closely with the current trauma team, social workers, and case managers we will map out patient selection, potential referrals, plan for long-term case management, and integration of case management into the current outpatient clinic setting. We plan to bring in a consultant from the National Network of Hospital-Based Violence Intervention Programs to provide tailored coaching and recommendations to NM. Under the grant, we will hire a trauma psychologist to provide trauma informed counseling to select trauma patients.
We anticipate that participants of the D2D program will gain effective coping skills. For example, on the pre-course survey participants rate their feelings towards being able to say no to situations that may get them in trouble or their ability to make changes in their life. After learning problem solving and risk/protective factors in D2D, we expect to see higher confidence levels. We anticipate the HBVIP will result in increasing enrollment rates, increasing number of referrals made, and lower attrition over time. Long-term success (>5 years) will be determined by decreases in reinjury rates, arrests/incarcerations, substance use, and violent deaths. We will also anticipate higher utilization of protective factors, such as staying in school, employment, extracurricular activities, and community ties.
- Expand referrals for D2D
- Analyze D2D data for program development
- Train D2D leaders
- Offer D2D at facilities outside the hospital
- Offer 25-hour/8 week anti-violence curriculum
- Train curriculum leaders
- Form D2D Parent’s group
- HBVIP needs analysis
- Complete consultation with NNHVIP
- Create referral network for HBVIP
- Strategic hiring of HBVIP staff
- Analyze HBVIP data for program development
Partnerships include: Roberto’s family, Omaha Police Department, Boys and Girls Club of the Midlands, YouTurn, Nebraska Medicine, UNMC Trauma team, UNMC Department of Surgery, UNMC College of Public Health, Omaha Mayor’s Office, Douglas County Youth Center, Douglas County Juvenile Probation Office, Douglas County Jail, Girls Inc., Boystown, Grief’s Recovery, Project Harmony
Effectiveness of the youth violence prevention program will be measured by: monitoring NM’s trauma database to see if a participant later presents as a trauma victim; changes in attitudes towards violence; and coping skills as seen when comparing pre and post surveys. We will survey participants again at 6 months to evaluate for coping skills retention. The HBVIP will be closely evaluated for enrollment rate, treatment plan, referrals, attrition, reinjuries, rearrests, incarcerations, employment, length of continued services, alcohol and drug use, weapon carrying, fighting, number of post discharge visits, and deaths. Evaluation will occur through referral records, monitoring of trauma database, police records, and post discharge phone calls. Dr. Melissa Tibbits from the College of Public Health at UNMC acts as the program’s research consultant and assists with evaluation design.