Health: Hospitals Expand Care to Address Violence at the Source

A hospital worker crosses Broad Street near Temple University Hospital on Nov. 11.

Text and images by Natalie Kerr.

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Amy Goldberg would like to be out of work.

As surgeon in chief at Temple University Hospital, Goldberg wants to never have another patient come into the trauma unit because of a gunshot wound. That’s why she started Temple Safety Net in 2005.

“For the longest time as a trauma surgeon, I felt that if all I was doing was operating on patients or taking care of patients, that I was really missing the mark,” Goldberg said. “Doing the preventive care, or education or all those other things, were really just as important to providing medical care.” 

Temple Safety Net is the front end of Temple University Hospital’s Trauma Unit — the component hoping to reach people before they need lifesaving services. Their programs — teaching youth about the consequences of gun violence, distributing gun locks and helping victims overcome trauma — are a reimagining of health care that begins outside of hospital walls.

But hospitals aren’t made to serve prevention work, nor are they rewarded for it financially. Preventive efforts defy the traditional role of hospitals, and expanding this work will require challenging systemic changes. However, it’s these efforts that will produce solutions to serve more than one gunshot victim at a time.  

Follow the Money 

Hospitals make money from patients in beds, not from healthy people in the community, said Samantha Matlin, vice president of learning and community impact at the Scattergood Foundation, an organization promoting behavioral health that operates out of Friends Center on Cherry Street and 15th in Center City. If prevention were financially prioritized, investment in gun violence programs would skyrocket.

“If hospitals were paid to keep people well, we’d see them organized differently, but they’re not,” Matlin said. “The hope of accountable care organizations was to do that, to create partnerships and community health homes, to keep people healthy, and well, we have not obviously realized that.”

The Scattergood Foundation is supporting a partnership between Temple Hospital and Central Division Victim Services, a nonprofit caring for witnesses and victims of crime in North Philadelphia, to connect people to services and create collaboration among gun violence organizations.

Temple Hospital and CDVS also receive grants from city and state programs that support their work, but consistent funding enables long-term planning and maximizes potential, Matlin said.

“We have to figure out sustainable ongoing core funding so that programs can function and not be in this like, ‘I hope we can keep the staff, I hope we can keep the lights on’, because that’s what’s going through these executive directors’ minds,” Matlin said. “That’s a horrible place to be.”

Organizations also use funds to collect data on program effectiveness, which helps secure further funding, said Kristen Romens, the project director for the Pew Fund for Health and Human Services.

Data is especially important during the current influx of funding for gun violence prevention programs due to increased gun deaths in Philadelphia, as it proves that programs produced meaningful results with the funds they received, Matlin said.

“If you have strong evidence of outcomes, that can be very convincing to other potential funders, so really contributing to the long-term sustainability of these programs,” Romens said.

The Pew Fund awarded two-year, $250,000 grants in July to three hospital-based gun violence intervention programs in Philadelphia, including Temple’s Trauma Victims Support Advocates program. The selected programs are critical providers of high quality victim services, Romens said.

Alongside the grants, The Pew Fund helps recipients establish databases and communicate key takeaways with stakeholders to attract future funding, Romens said. This helps programs like Temple’s, which are still figuring out what data is meaningful to track long-term, to demonstrate the outcomes of their programs.

“They definitely would want to break the cycle of violence, retaliation, etc., but they still need to build evidence that that really happens,” Romens said.

Standard programs at CDVS like counseling services, court accompaniment and victim compensation advocacy are funded by grants from the Western District of Pennsylvania office of the U.S. Attorney General. But for any other resources they want to offer or programs they want to start, CDVS must apply for additional grants, said Tijania Goodwin, community awareness and marketing coordinator.

Grants often can only be used for specific projects or for programs that last for an allotted period of time and CDVS must compete with other organizations in Philadelphia doing similar work that also need funding, Goodwin said.

“If you’re a big nonprofit or a small nonprofit, there’s always going to be an issue getting funded,” Goodwin said. “The good thing is that the DA’s office and Harrisburg and stuff does fund these kinds of organizations, but we also can’t just rely on one thing,”

Temple Safety Net uses grants from the Pennsylvania Department of Justice and the Pennsylvania Commission on Crime and Delinquency to fund case managers, 24/7 victim advocates and a social worker to help patients and families with insurance bills, follow-up appointments, writing resumes to help them transition back into the workforce and post-traumatic stress, Goldberg said.  

Temple is working with The Pew Fund on a database tracking which resources patients accessed to show the utility of the programs, which should help them continue to earn grants, Goldberg said.

“It is critical to secure additional funding so that the work that you’re doing doesn’t go away,” Goldberg said. “I could be idealistic to say, if you do a good job, and you communicate that to the hospital, etc, that most people will do what’s right.” 

People are becoming more interested in a public health approach to addressing gun violence, but true dedication requires deep investment in programs that provide public health services, said Jessica Beard, associate professor of surgery at the Lewis Katz School of Medicine, trauma surgeon and director of research for the Philadelphia Center for Gun Violence Reporting.

A possible method for sustainable funding could be billing insurance providers for services provided to violent injury victims, like case management and psychological services, but this is not yet a widely explored alternative, Beard said.

“In a perfect world, there would just be funding for it and it would be an integrated part of the services that we provide,” Beard said. “Every trauma center would be sort of required to have them, but also get support for them.”

Shifting Views Towards Gun Violence 

In 1995, the federal Dickey Amendment passed after months of pressure from gun lobbies. It prohibited using federal funds to promote gun control and censored science — blocking national public health agencies like the Centers for Disease Control and Prevention from conducting gun violence research for more than 20 years.

Research into the causes of gun violence and effective prevention methods remains anemic, creating roadblocks to legitimize prevention work and develop best practices for addressing violence, said Bill Aaronson, a professor of health services, administration and policy and the director for the health policy and management program at Temple University.

“There is not an evidence base that can support program development, other than what people really believe in their hearts are the ways in which we can reduce gun violence,” Aaronson said.

Health care systems are beginning to treat gun violence as a public health issue, but gun lobbies’ suppression of gun violence legislation and research allowed the crisis to reach epidemic levels.

In 2016, the American Medical Association labeled gun violence a public health crisis to pressure legislators to increase public health funding toward gun violence prevention, Aaronson said. The Affordable Care Act also requires health care organizations conduct a Community Health Needs Assessment and work with the community to address the findings.

Though funding is a challenge, hospitals have a vested financial interest in expanding prevention efforts to reduce treatment costs, Aaronson said.

Hospitals generate revenue when patients pay for care through public insurance like Medicare and Medicaid or private insurers, or when uninsured, out of pocket. But more than half of all hospitals in the U.S. are expected to be in the red this year, according to a 2022 report from consulting firm Kaufman Hall for the American Hospital Association.

About 68 percent of patients in a typical hospital have Medicare or Medicaid, but these programs don’t cover the full cost of care, leaving hospitals billions of dollars short each year, according to the AHA’s 2017 Hospital Billing Factsheet.

Tax-exempt hospitals like Temple also cannot bill patients the full amount of their care if they are eligible for financial aid under the hospital’s policy, so payments from privately-insured patients have to make up for the lost revenue. Otherwise, the hospital is left without full compensation.

Investing in prevention and trauma-informed care helps hospitals see fewer visits to the emergency room and trauma unit, which require expensive procedures, and fewer readmissions, which hospitals are penalized for, Aaronson said. Many victims and perpetrators also don’t have health insurance, so they pay very little or nothing for the care they receive.

Gun violence costs the United States more than $1 billion a year in hospital bills, according to a 2021 report by the United States Government Accountability Office.

Research is key to implementing a public health approach, Beard said.

The first step of the CDC’s Public Health Approach to Violence Prevention is to analyze data like where violence occurs, the number of violent injuries and deaths and violence-related behaviors to understand important patterns.

But right now, there is no national data source for nonfatal firearm injuries, nor is there sufficient science on the impacts of structural racism, prolonged disinvestment or place-based risk factors, Beard said. If violence declines in Philadelphia, it will be difficult to know what caused that change and repeat those measures.

Public-health strategies to violence are gaining traction, but in general people remain uneducated about what those strategies are and their benefits, said  Ruth Abaya, attending physician in the emergency department at Children’s Hospital of Philadelphia and the program manager for the Philadelphia Department of Public Health’s Injury Prevention Program.

While people often support a public-health approach to gun violence as a concept, they are more hesitant when it comes to implementation, and are more comfortable relying on traditional methods like police intervention, Abaya said.

But public-health approaches can intervene in violence both before and while it’s happening and provide more holistic support to victims, ease overburdened police departments and ensure that violence responses aren’t generating harm from increased police presence in communities, Abaya said.

“This can’t just be their show, there have to be other supportive partners who are working upstream to prevent violence before it happens,” Abaya said. “People get that once you explain it, but for a lot of people, they haven’t really heard it explained.”

We All Want The Same Thing

Aaron Wells is trying to pay forward the support he received from his mentor and former Police Athletic League Officer Harold Barnes. He sees himself in many of the youth he works with at the North Philly Project, an organization supporting North Philadelphia youth and families, where he is executive director.

NPP doesn’t have a physical location. They work in recreation centers, at partner programs or virtually on Facebook and other platforms because Wells doesn’t want to wait for people to come to him in need, he wants to find the problem and be the solution.

“It isn’t build it and they’ll come, it’s let’s go out into the community and find out where needs are, and how we can bring programming to address those needs,” Wells said.

Wells feels that local health care resources are lacking in programs embedded in communities like mobile clinics, health care education, school clinics and partnerships with local nonprofits, and tend to instead operate out of enormous systems that are difficult to navigate and intimidating to approach.

“The neighborhood clinic has got to come back, and it can be a representation of the largest system, not a problem there, but that has to return,” Wells said. “Health care right now is ‘come to me.’”

It’s a responsibility for both large entities like Temple Hospital and smaller nonprofits like NPP to make connections, Wells added. But it’s difficult to create partnerships if Temple doesn’t communicate and discern what mutual interests they share with the community.

But it’s possible — NPP partners with CHOP on their nutrition and wellness programs, Close the Gap and the Wellness and You program, to give people the information and resources they need to care for their physical health.

“There are examples, very good, strong examples of partnership and cooperation,” Wells said. “To extend that and to sustain it, my thought is that we both have to find what our mutual interest is in communities.”

Partnering with community organizations or schools who also support and care for the community will help Temple Hospital maximize their impact, especially since violence prevention isn’t their primary focus, said Aisha Winfield, program director at the Blues Babe Foundation, a nonprofit on Broad Street near Dauphin that provides after-school and summer programming for kids and teens.

“Partnerships are critical because we know that one entity, even a hospital, can’t do everything,” Winfield said.

Hospitals are not fully equipped to properly address gun violence prevention at the level it needs to be, but starting at the ground level and working with organizations that have strong community relationships can help identify and connect with the issue, Beard said.

As long as hospitals are individual actors primarily focused on treating illness and not maintaining public health, impacts from disinvestment and structural racism will continue to be major social determinants of health, Beard said.

Hospitals have a responsibility to think about issues like affordable housing, access to healthy food, criminal justice and structural racism that influence people’s health behaviors, Matlin said.

“You can have the best teams and outreach for health care, but if you’re not addressing the social determinants, we’re not going to get there,” Matlin added.

Ultimately the solution will involve widespread changes to community infrastructure in education, employment, poverty and the environment people live in, Abaya said.  

“That’s what would change violence in a large way,” Abaya said. “It’s for communities to be transformed, for them to be cohesive, for there to be good relationships between different community members, for there to be better support systems.”

But changes are beginning to take root as different health care providers introduce more prevention-based efforts into their services, Goldberg said. For health care practitioners who see the effects of guns every day, this feels like a personal responsibility.

“We’d all want to be put out of business, right?” Goldberg said. “I would hope that I would never have to take care of another patient again. That’s ultimately what we want. So all of us — Drexel, and CHOP and Temple. We all want to work together because we all want the same thing.” 

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