How Health Care Providers Can Respond to Gun Violence

Joseph Richardson, Ph.D., a University of Maryland professor and medical anthropologist, has spent the last 10 years traversing two seemingly disparate worlds: Black communities affected by gun violence and the hospitals that treat its victims. Growing up in a working-class neighborhood of Philadelphia, Richardson experienced the trauma of violence firsthand. He witnessed his first shooting at 14. Soon after, his uncle was murdered.

Richardson has written extensively about how he and his colleagues persuaded young men who were deeply distrustful of the health care system to seek treatment for the trauma they’d experienced — not just from their near-fatal firearm injuries, but also from growing up around gunfire in impoverished neighborhoods fractured by mass-incarceration practices. His documentary, Life After the Gunshot, created in partnership with Che Bullock, one of the men he mentored, is a moving testament to the healing power of compassion and to Richardson’s remarkable ability to persuade people, some so wary they bring guns to appointments with him, to drop their guard and join him on a path to recovery.

The film follows 10 men from the District of Columbia who participated in a hospital-based violence intervention program, one of about 50 in the United States offering victims of violence a range of supports like therapy and help with finding a job, all in hopes of reducing the risk of retaliation or reinjury. Studies have found that without such supports, more than 60 percent of people who experience a violent injury will be readmitted for another within their lifetime. For the men in the film — many of whom had been shot or stabbed multiple times — any sense of safety or faith in the world has been shattered long before they were physically injured. By enabling them to come to terms with the harsh reality of their childhoods and the profound effects of structural racism, the program — particularly a peer support group co-led by Bullock — becomes a turning point in their lives.

It’s not easy work for anyone involved: not the patients, who still hear gunfire while trying to recover; not the social workers and peer support workers, who witness death on a near-weekly basis; and not the trauma surgeons and ED physicians, who know the health care system is only just beginning to grapple with complex trauma.

Despite these challenges, an increasing number of clinicians and hospital CEOs are stepping forward to insist that the health system play a greater role in preventing gun violence in all its forms.

In this issue of Transforming Care, we describe the efforts of health care providers to develop a more comprehensive response to gun violence, one modeled on public health campaigns targeting cigarette smoking and car accidents. Like those campaigns, gun violence prevention efforts focus on screening and surveillance to identify people at risk and reveal patterns of injury. They also develop, test, and evaluate novel approaches to treating gun violence, often in partnership with the communities most affected by it. Other initiatives focus on public awareness and provider education, aiming to make firearm injury prevention an expected part of health care delivery.

With the passage of the Bipartisan Safer Communities Act, more health systems are expected to follow suit. The law allocates $250 million for community violence interruption programs that adopt a public health approach to reducing gun violence. It also provides $750 million for crisis response services, including implementation of extreme-risk protection orders. Several new organizations have been established to provide technical support to hospitals engaged in this work, among them the Northwell Health Center for Gun Violence Prevention and Kaiser Permanente’s Center for Gun Violence Research and Education, which is co-led by the Health Alliance for Violence Intervention. These centers also fund research to build the evidence base for effectively engaging the highest-need patients in clinical and community settings.

Mainstreaming Firearm Injury Prevention

Northwell Health, the largest health system in New York, launched its campaign to prevent firearm injuries in 2019, when its Irish-born CEO, Michael Dowling, took out a full page in the New York Times exhorting fellow health care leaders to use their influence and workforces to combat gun violence. Within four years, more than 55 hospital executives had joined Dowling in creating a CEO Council, a national coalition of health system leaders committed to depolarizing the issue of gun safety.

The health system’s Center for Gun Violence Prevention is led by Chethan Sathya, M.D., M.Sc., a pediatric trauma surgeon who has operated on many children with firearm injuries, including a six-month-old baby whose spinal cord was severed by a bullet as she sat in a car seat. “She survived but is paralyzed to this day,” Sathya says.

Northwell Health has been developing and testing the effectiveness of a screening tool that assesses an individual’s firearm injury risk, which is elevated for children living or playing in a home where guns are not safely stored and for anyone living in a neighborhood where gunfire is common. Funded with a $1.4 million grant from the National Institutes of Health, the survey sidesteps the contentious debate over gun ownership by asking patients more neutral questions, such as, “Do you have access to a gun within or outside of your household?” and “How many times have you had a gun pulled on you?”

The results are scored and stored in the patient’s electronic medical record to guide discussions about next steps for care, which range from firearm safety counseling to referrals to community-based programs that offer jobs, mentorship, and other supports to people who might otherwise rely on gangs and guns for safety. The screening tool was first piloted in three Northwell hospitals with busy trauma centers, but the goal is to use it consistently throughout the 21-hospital system, including its more than 850 outpatient clinics.

As part of its campaign “We Ask Everyone. Firearm Safety Is a Health Issue,” the health system has communicated to physicians, nurses, and social workers the message that preventing gun violence is as important as preventing cancer and heart disease. It took a year of education, Sathya says, but clinicians have become more comfortable with asking and answering questions. “We’ve reached the point where people are begging to get on board, which is very different from two years ago,” he says.

To date, more than 25,000 patients have been screened. Data from these and future screenings will be used to assess whether the tool is correctly identifying risk factors.

Making It Easier to Act on Threats of Violence

In 2023, the Johns Hopkins Center for Gun Violence Solutions, based at the Bloomberg School of Public Health in Baltimore, received $2 million from the U.S. Department of Justice to support an array of agencies and individuals involved in implementing extreme-risk protection orders (ERPOs), a civil procedure that enables law enforcement, family members in most states, and licensed health care providers in some states to petition a court to temporarily restrict access to guns for people who are at risk of harming themselves or others.

Twenty-one states and the District of Columbia have enacted such “red flag” laws in hopes of preventing mass shootings and other interpersonal violence, as well as suicides. The petitions are most often initiated by police or family members; there’s been far less uptake by health care providers, even though they frequently see patients in crisis. Part of the reason is that there are a host of legal, logistical, and administrative barriers to petitioning for an ERPO, says Shannon Frattaroli, Ph.D., M.P.H., one of the principal investigators for the grant. For one, it’s a time-consuming process requiring multiple in-person court appearances, a challenge for most clinicians. Another impediment is the concern that filing an ERPO will undermine a relationship with a patient, Frattaroli says.

Still, Maryland has the highest per capita rate of ERPOs, driven by champions in law enforcement who have encouraged their use, as well as by advance work done to educate court staff and others about the process. To promote use of these orders in health care settings, a team at Johns Hopkins sought to reduce the administrative burden on health care providers by partnering with Baltimore Crisis Response, which offers support for managing ERPO petitions. This pilot strategy allows practitioners within the health system to take advantage of the established relationships crisis counselors have in local neighborhoods and their flexibility to participate in court hearings. Another option for hospitals is to assign responsibility for ERPOs to in-house specialists who assume the administrative burden of filing them. “We’re finding that having licensed social workers on the team to manage the whole process can make it a much more viable strategy,” Frattaroli says.

Supporting Survivors Through Hospital-Based Interventions

Hospital-based violence intervention programs (HVIPs) like the one Joseph Richardson helped to create are a vital component of the health system’s response to gun violence. The first HVIP was launched in Oakland, Calif., in 1994 in collaboration with Sherman Spears, a survivor of gun violence. Similar programs were founded a few years later in Milwaukee and Baltimore.

HVIPs are multidisciplinary programs, typically involving people with firsthand experience of violence who try to gain people’s trust, engaging them while they’re still in the emergency department or hospital. Teams of social workers, therapists, clinicians, and other professionals then provide wraparound support to meet immediate needs while offering longer-term social and emotional supports to aid fuller recovery.

A “Prescription for Hope”

Lisa Harris, M.D., the CEO of Eskenazi Health, a safety-net hospital system in Indianapolis, and Gerardo Gomez, M.D., a trauma surgeon, were inspired to create Prescription for Hope in 2009 after learning about a similar HVIP at the University of California, San Francisco. The program deploys a violence intervention specialist to offer services to anyone in the hospital recovering from gunshot wounds, stabbings, or other assaults.

If people choose to enroll in the program — about 20 percent eventually do — they are assigned a violence intervention specialist, as well as a case manager who connects them with a wide range of supports. In the months following an assault, people often need help finding health insurance, follow-up care, safe housing, and transportation; they may also need an advocate as they return to work or school or address legal issues. Patients are also encouraged to see the program’s therapist or another behavioral health professional for help with emotional processing and management of acute stress and traumatic grief. “There’s a stigma around getting help with therapy,” says Sherri Marley, R.N., Eskenazi’s trauma program manager. “You want to take that teachable moment to connect people to help.”

Some patients have had so much cumulative trauma in their lives that a shooting doesn’t seem all that unusual. They may also be skeptical that the health system can help them, says Blakney Brooks, M.P.H., the program’s injury prevention coordinator. “Staff build rapport by saying, ‘You have survived this time and you’ve done a good job,’” she says. “‘But here’s where we can fill in those gaps to help you get to that next level so that you’re no longer surviving. Now you’re living a life.’”

The program costs about $900,000 a year, funded mostly through public and private grants. An evaluation found a relatively low rate of repeat violent injuries, 4.4 percent, compared to 30 percent prior to initiating the program.

Damaris Ortiz, M.D., a critical care surgeon and Prescription for Hope’s medical director, has been leading research on survivors’ experiences in an effort to improve the program. With a particular interest in the association between posttraumatic stress disorder and surgical outcomes, she and her colleagues have been tracking the mental health, quality of life, and sense of self-efficacy reported by patients who’ve been assaulted. “A lot of clients come into programs like ours with chronic, complex posttraumatic stress disorder, and yet most trauma centers don’t have the resources, staff, or a robust referral network to address those issues,” Ortiz says. Better data collection may build the case for funding those supports.

Ortiz is also partnering with other local researchers and three Indianapolis Level 1 trauma centers to build a registry of violent assaults. “We want to get a granular picture of what’s going on with firearm injuries in Indianapolis. Not just the regions and streets where there are shootings, but what happens to individuals after they’ve been injured,” she says. “What kind of health care needs do they have, what resources did they access or not access, or was it difficult for them to access. Then we will be able to develop interventions and collaborate with existing community resources to meet people’s longer-term needs.”

An “Antifragility” Initiative

Edward Barksdale, Jr., M.D., grew up in the Jim Crow South. As a boy, he was interested in trying to make pottery but the only classes available were for white children only. In reading about pottery, he learned about the Japanese kintsugi (“golden repair”) technique, a process of mending broken pottery with gold or silver lacquer. That broken things can be fixed and made stronger became the operating principle behind the Antifragility Initiative, which Barksdale founded at Cleveland’s UH Rainbow Babies & Children’s Hospital, where he is surgeon-in-chief, in 2019.

The program is designed to help teens who have been violently assaulted, as well as their families, make positive changes in their lives. Social workers reach out to teens in the hospital and their family members soon after an assault to take advantage of the “golden hour” when they may be receptive to help. “You can take the toughest person — typically a young African American male who a week later sees his gunshot wound as a badge of his courage. But in that moment, they may feel vulnerable,” says Barksdale. “And we felt that if we could leverage that moment, that we could create connection.”

Social workers then visit participants’ homes in the days after discharge to perform a comprehensive assessment, taking into account families’ health, social, and emotional needs. All participants are offered cognitive behavioral therapy to develop coping skills and to process the trauma. In addition, the program pairs teens with activities that are customized to their interests. Some young people take arts education classes at Karamu House, a community organization that includes the oldest Black theater in the country, while others are mentored by members of the Peacemakers Alliance, a violence prevention group that includes former gang members. Teens left with physical disabilities or paralysis from their injuries may be partnered with someone living with similar impairments. Program staff help the whole family — for example, a father who was dealing with his anger and skyrocketing blood pressure after his son had been shot during a robbery.

The program offers families a wide variety of social supports, informed by research undertaken at Case Western Reserve University showing that victims of violent assaults treated at UH Rainbow Babies & Children’s Hospital in 2017–2018 had often experienced profound adversity from an early age. Victims of violent assaults were overwhelmingly Black (97% of gunshot victims and 92% of assault victims) and lived in some of the city’s poorest neighborhoods. Two of five assault victims had experienced lead poisoning, and two of three had been the subject of an abuse or neglect investigation before their injury.

Program staff connect families to services through the food bank, housing authority, transportation authority, and other community partners. Barksdale sees the issue of food insecurity as particularly salient. “We find that many of our kids leave home to find food,” he says. “Fifty-four percent of our violence victims admit to food insecurity.”

Among the 436 patients who participated in the Antifragility Initiative from June 2019 to June 2023, only 12 (less than 3%) had experienced recurrent gunshot injuries, according to Barksdale. By contrast, there was a 30 percent rate of recurrent gunshot injuries within two years among all victims treated at UH Rainbow Babies & Children’s Hospital during 2016–2018. The program’s annual budget is about $600,000, with most of the funds coming from the county, the Victims of Crime Act, and local philanthropy. Barksdale himself subsidizes the shortfall.

Preventing Gun Violence: Key Lessons

Many of the models designed to prevent and respond to gun violence were developed by a core group of clinicians, researchers, and community leaders. As they seek to support survivors and prevent further violence, health systems can draw lessons from innovative programs from across the U.S.

The most advanced programs have some common features: dedicated leadership, strong community partnerships, and the provision of comprehensive support services, led by staff who offer empathetic, culturally responsive care. The latter is key, according to Fatimah Loren Dreier, M.B.A., executive director of the Health Alliance for Violence Intervention. “Trust is one of the core skills and assets that we have in the violence prevention professional,” she says. “Their ability to connect based on shared experience is essential. That’s why we seek ‘credible messengers’ for these roles, people who often have deep roots in the community, many of whom have experienced violence firsthand. And while the violence prevention professional has a unique role, the best programs ensure that trauma-informed care is provided by all who interact with the individual.”

The experiences of health systems featured here offer other lessons on how to strengthen gun violence prevention and treatment programs.

Create flexible models of care for survivors of gun violence. Traditional therapy models that offer weekly, time-limited appointments with providers may be insufficient to support gun violence survivors, particularly those who are uninsured or have Medicaid coverage. Eskenazi Health operates a community mental health center that offers flexible, wraparound services, including case management led by peer counselors and trauma experts. Patients are connected to resources that address their trauma symptoms and other challenges, like maintaining employment, securing safe housing and transportation, and navigating legal services.

Certified community behavioral health clinics (CCBHCs) are another vehicle for expanding access to peer-delivered, peer-operated, culturally competent services in community settings. Designed to provide 24/7 access to coordinated, comprehensive behavioral and physical health care navigation services, regardless of one’s ability to pay, CCBHCs can hire and pay for peer counselors in ways that traditional health care systems cannot. The Bipartisan Safer Communities Act offers funding to establish these centers, which could partner with existing health systems to provide community-based care. While not yet widespread, they show promising results at delivering high-quality care.

Enhance training and supports for staff. While peer mentors, trauma experts, and other members of violence interruption program teams play a pivotal role in treating victims of gun violence, they are often undercompensated and prone to burnout. Programs would benefit from greater investment in these team members, including on-the-job support to help them cope with the vicarious trauma associated with treating victims of violence.

More training is becoming available to health system staff. The Community Violence Intervention Leadership Academy at the University of Chicago aims to equip the next generation of community violence intervention leaders with the tools they need to build, run, and evaluate programs. The six-month training covers strategies for fundraising and staff retention, among other topics.

Learning collaboratives are another way of building community and sharing lessons. Northwell Health's Gun Violence Prevention Learning Collaborative supports staff from 600 hospitals in 38 states as they work through the challenges of developing suicide prevention and ERPO programs, as well as HVIPs. Participants include frontline workers — emergency department doctors, trauma surgeons, injury prevention coordinators — as well as administrative leaders.

Develop sustainable funding for gun violence prevention and intervention. Many programs have struggled to stay afloat when funding is insufficient and inconsistent or when an executive champion leaves. The Bipartisan Safer Communities Act has made more funding available for community violence interventions, but institutional support is also needed to ensure that programs succeed.

HAVI has advocated for Medicaid payment for violence prevention professionals, resulting in a designation in the National Uniform Claims Code. Seven states now have a Medicaid benefit for violence prevention services. Dreier notes that bundled payments to providers of care for victims of gun violence might create incentives to provide comprehensive services.

Build the evidence base of what works. Early in her career as an emergency medicine physician and public health researcher, mentors and colleagues of Megan Ranney, M.D., M.P.H., dean of the Yale School of Public Health, told her to stay away from the topic of firearm injury because it wasn’t feasible to study it as a health problem. But that has begun to change, thanks to new funding and partnerships. There are now nascent efforts to understand gun violence and what can work to prevent it, including those of the new Research Society for the Prevention of Firearm-Related Harms.

“There have been a couple of decent approximations of firearm injury patterns on state and county levels, but not much done on an individual city, metropolitan or non-metropolitan area level as to injury, risk, and protective factors,” Ranney says. “And there’s virtually no data on the secondary trauma from exposure to firearm injury.… We are lacking even more in terms of what we do once we know who is at risk and what the protective factors are.”

The Kaiser Permanente Center for Gun Violence Research and Education, coordinated through a partnership with HAVI, offers grants to build the evidence base of what works, with researchers working closely with community partners. “The center has a very explicit health equity focus,” says Dreier. “We also care very much about education initiatives. How do we clinicians, as well as public health professionals, understand violence as a health issue and change narratives about violence in this country?”