Hospital-Based Violence Intervention Programs: A Guide to Implementation and Costing

“Not every injured person is reflected in a police report—but they are coming to the emergency department. Crisis resources especially have to be a piece of how we plan [our budgets], because when you don’t have a home, don’t have food, don’t have insurance—it’s hard to heal. When HVIPs are well funded, they’re able to cast a wider net and make a bigger impact.”

—Kenya Jackson, Violence Prevention Research Manager, Interrupting Violence with Youth and Young Adults (IVVY) Project at Grady Health System, Atlanta

Role of HVIPs in Reducing Violence

Governments and community members pay a steep price for persistent gun violence, including the costs of lives taken, police response, incarceration, medical care (both acute and long-term), and loss of income. Hospitals carry this financial burden too. In the first year post-injury alone, nonfatal firearm assault injuries cost an estimated $37,435 in medical expenses¹Cora Peterson, Likang Xu, and Curtis Florence, “Average Medical Cost of Fatal and Non-Fatal Injuries by Type in the USA.” Injury Prevention 27, no 1 (February 2021): 24–33, http://doi.org/10.1136/injuryprev-2019-043544.—much of which hospitals carry when survivors are underinsured, as is often the case.²Faiz Gani, Joseph V. Sakran, and Joseph K. Canner, “Emergency Department Visits for Firearm-Related Injuries in the United States, 2006–14.” Health Affairs 36, no. 10 (October 2017), https://doi.org/10.1377/hlthaff.2017.0625. And because research shows prior violent injuries are a risk factor for future ones,³Ali Rowhani-Rahbar et al., “Firearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration.” Annals of Internal Medicine 162, no. 7 (April 7, 2015), https://doi.org/10.7326/M14-2362. these costs can balloon quickly without intervention.

What Steps Can Cities Take to Prevent Violence in Their Communities?

A growing body of evidence highlights one promising intervention: HVIPs. People working in HVIPs recognize that there is a unique window of opportunity to connect survivors with services and prevent reinjury and retaliation. VPPs begin outreach at violence survivors’ hospital bedsides, then continue engagement over the next 6 to 12 months, offering crisis intervention, counseling, and referrals to services such as job training, housing assistance, drug and alcohol counseling, and more.⁴The Health Alliance for Violence Intervention, “Standards and Indicators.”

What Are the Benefits?

Promising research shows that HVIPs are associated with reduced risks of future violence and crime. Studies conducted in Baltimore, Indianapolis, New York City, and San Francisco all found that HVIP participants’ reinjury rates were at least 50 percent lower than nonparticipants’—over periods ranging from two months to six years after they had completed the program.⁶Catherine Juillard et al., “A Decade of Hospital-Based Violence Intervention: Benefits and Shortcomings,” Journal of Trauma and Acute Care Surgery 81, no. 6 (December 2016): 1156–61, https://doi.org/10.1097/TA.0000000000001261; Noé Romo et al., “Improving Adolescent Violent Trauma Outcomes with a Hospital-Based Violence Prevention Initiative,” Hospital Pediatrics 13, no. 2 (January 2023): 153–58, https://doi.org/10.1542/hpeds.2021-006428; Carnell Cooper, Dawn M. Eslinger, and Paul D. Stolley, “Hospital-Based Violence Intervention Programs Work,” Journal of Trauma: Injury, Infection, and Critical Care 61, no. 3 (September 2006): 534–37, https://doi.org/10.1097/01.ta.0000236576.81860.8c; Gerardo Gomez et al., “Project Prescription for Hope (RxH): Trauma Surgeons and Community Aligned to Reduce Injury Recidivism Caused by Violence,” American Surgeon 78, no. 9 (September 2012): https://doi.org/10.1177/000313481207800942.

Studies also found reductions in subsequent misdemeanors and violent crimes, including fewer arrests and convictions and shorter sentences.⁷Cooper, Eslinger, and Stolley, “Hospital-Based Violence Intervention Programs Work;” Marla G. Becker et al., “Caught in the Crossfire: The Effects of a Peer-Based Intervention Program for Violently Injured Youth,” Journal of Adolescent Health 34, no. 3 (March 2004): 177–83, https://doi.org/10.1016/j.jadohealth.2003.04.001; Tina L. Cheng et al., “Effectiveness of a Mentor-Implemented, Violence Prevention Intervention for Assault-Injured Youth Presenting to the Emergency Department: Results of a Randomized Trial,” Pediatrics 122, no. 5 (November 2008): 938–46, http://dx.doi.org/10.1542/peds.2007-2096. Likely contributing to these outcomes, HVIP participants also demonstrate improved mental health,⁸Elizabeth Gorman et al., “Beyond Recidivism: Hospital-Based Violence Intervention and Early Health and Social Outcomes,” Journal of the American College of Surgeons 235, no. 6 (December 2022): 927–39, https://doi.org/10.1097/XCS.0000000000000409; Michael N. Levas, Emmalee A. Boyle, Marlene Melzer-Lange, and Julie Panepinto, “Improvement in Quality of Life among Violently Injured Youth after a Brief Intervention,” Journal of Trauma and Acute Care Surgery 81, no. 4 (October 2016): S61–S66, https://doi.org/10.1097/TA.0000000000001061. greater attendance at medical appointments,⁹Romo et al., “Improving Adolescent Violent Trauma Outcomes.” and use of local services.¹⁰Michel B. Aboutanos et al., “Brief Violence Interventions with Community Case Management Services Are Effective for High-Risk Trauma Patients,” Journal of Trauma and Acute Care Surgery 71, no. 1 (July 2011): 228–37, https://doi.org/10.1097/TA.0b013e31821e0c86.  

These programs are even more important because gun violence does not affect everyone in the United States equally. Interpersonal gun violence is often concentrated geographically, with young Black and brown men living in the country’s most underinvested urban communities suffering from the highest rates of gun homicides and nonfatal injuries.¹¹Melissa Tracy, Anthony A Braga, and Andrew V Papachristos, “The Transmission of Gun and Other Weapon-Involved Violence within Social Networks,” Epidemiologic Reviews, Volume 38, no. 1 ( January 2016): 70–86, http://doi.org/10.1093/epirev/mxv009; Everytown Research analysis of Centers for Disease Control and Prevention, National Center for Health Statistics, WONDER, Underlying Cause of Death 2018–2021. HVIPs play a vital role in helping survivors connect with continued services, care, and support, which can otherwise be difficult to navigate alone. By connecting survivors—many of whom return to under-resourced neighborhoods—with continued care and services, HVIPs help ensure that they have ongoing access to support and care within their communities.

Community-based organizations and hospitals looking for guidance on how to develop, implement, and secure funding for an HVIP can visit the HAVI’s website for related resources.¹²The Health Alliance For Violence Intervention, https://www.thehavi.org/.  With this guide, Everytown and the HAVI aim to help cities and funders understand the key costs of implementing HVIPs. To make the process simpler, Everytown and the HAVI created a costing tool that can be tailored to specific needs and budgets by adjusting for factors like cost of living, program size, inflation, crisis support needs, and others. This tool was developed using a rigorous methodology known as a bottom-up ingredient-based approach, which itemizes key HVIP resources based on interviews with program staff and analysis of at least five sample program budgets.¹³For more information about the methods used to develop this costing tool, see “Methodology” below.

Implementing an HVIP: Roles and Responsibilities

Who Do They Serve?

HVIP participants typically include youth and young adult survivors of nonfatal, assault-related violent injuries.¹⁴The Health Alliance for Violence Intervention, “Standards and Indicators for Hospital-Based Violence Intervention Programs.” Survivors of intimate partner violence and self-inflicted injury are frequently excluded due to differing needs. Some HVIPs are further tailored to children and teens, gun violence survivors, people with prior justice system contact or disabilities, or other more narrowly defined groups to help ensure that funds can meet demands and address their unique needs. HVIP best practices include collaborative review of hospital and law enforcement datasets to identify a target population based on trends in patient volume and reinjury or retaliation risks.

Who’s Involved?

HVIPs can be either hospital-linked (that is, led by the community-based organization) or hospital-based (led by the hospital). Hospital-linked programs often benefit from strong existing community relationships and low indirect costs, while hospital-based programs frequently benefit from improved data access and regional scalability. Although different organizational structures exist, a hospital-linked example is outlined below:

HVIP Organizational Structure

Community Based Organization

Role: Provide crisis intervention, counseling, service connections, emergency resource distribution, and case management.

Hospital

Role: House the program, identify participants, and provide medical care.

External Service Providers

Role: Receive referrals and enroll participants in wraparound services (such as job training, housing assistance, drug and alcohol counseling).

The local community-based organization in this example leads program development, implementation, training, and coordination. It does so by offering immediate services at the hospital bedside like crisis intervention, needs assessment, retaliation de-escalation, emergency resource provision, and family support.¹⁵The Health Alliance for Violence Intervention “Standards and Indicators for Hospital-Based Violence Intervention Programs.” In the longer term, participants receive sustained case management, connections to local services, support in enrolling and attending their first few appointments, access to counseling, mentorship, and more. The length of engagement varies based on participant needs, but typically spans from 6 to 12 months.

The hospital in this example is one with an emergency department or trauma center serving at least 100 patients with nonfatal violence-related injuries annually. It houses the program, provides access to data, identifies eligible participants, and provides them with emergency medical care.¹⁶The Health Alliance for Violence Intervention “Standards and Indicators for Hospital-based Violence Intervention Programs.” Hospital contributions (such as a small portion of staff time plus a physical space) are often made in-kind and not included here as HVIP costs, particularly since the presence of these programs benefits hospital productivity by reducing readmissions and complements routine efforts to treat patients medically.

External service providers are also key to an HVIP’s success. Survivors of nonfatal violent injuries often need assistance to help ensure their immediate safety, prevent retaliation, access food and shelter, navigate victims’ compensation and health insurance, address substance-related challenges, attain employment or education, and address other needs.¹⁷The Health Alliance for Violence Intervention, “Transformative Guidance on Victim Services Funding for Hospital-Based Violence Intervention Program,” June 2022, https://static1.squarespace.com/static/5d6f61730a2b610001135b79/t/628be626f63ee8417a6262f7/1653341336749/HAVI-VOCA-toolkit.pdf. A single organization or program can rarely provide all of these services. By building strong relationships with external service providers, HVIPs can make and follow up on referrals to other programs, to help make sure that participants receive the distinct types of support they need. External service providers are not typically included in HVIP budgets.

Calculating the Costs

The budget for an HVIP is divided into four major categories: staff, transportation, crisis support resources, and operations, with an additional line for indirect costs. The total cost will depend on several factors, such as the number of participants served, whether the hospital or a community-based organization leads the program, if it operates in a single hospital or a regional network of hospitals, and the types and extent of crisis support needed. 

As an example, Everytown and the HAVI estimate that an HVIP that serves 100 participants annually, is led by a community-based organization, has a 15 percent rate of indirect costs, and operates out of one midsize city hospital’s emergency department will cost, on average, $1,079,818 annually for at least the first three years—$10,798 per participant.

Example of HVIP Costing Breakdown

To estimate the costs for your program, you can use the HVIP costing tool available below to edit key program parameters easily.¹⁸For more information about the methods used to develop this costing tool, see “Methodology” below.

Key Costing Ingredients

Staff

Staffing depends on program size, but in our example, Everytown and the HAVI assume that the HVIP will have eight full-time paid staff members: one director, one intervention supervisor, four violence prevention professionals, one clinical supervisor, and one administrator. The director leads program development, strategy, fundraising, and relationship-building. The intervention supervisor trains, supervises, and evaluates VPPs. The VPPs—sometimes also referred to as violence intervention specialists, credible messengers, or case managers—are the crux of HVIP service delivery, providing culturally competent crisis intervention, assessment, case management, resource and service connections, and ongoing support. In some instances—though not in this cost analysis—social workers rather than VPPs provide these services. The clinical supervisor provides trauma-informed therapy and supervision. The administrator is responsible for program operations, assessment, and evaluation. Budgets should ensure livable wages¹⁹The Health Alliance for Violence Intervention, “Resources on Public Funding for Community Violence Intervention (CVI),” https://www.thehavi.org/public-funding-for-violence-intervention; Urban Peace Institute, “LA Peace Plan,” October 20, 2022, https://www.urbanpeaceinstitute.org/in-the-news/2022/10/20/la-peace-plan. and include competitive benefits packages, with resources available for mental and physical health and life insurance, credentials and professional development, phone plans, retirement savings, and annual raises.

Transportation

Getting established in new programs and groups during a period of trauma and physical injury often poses challenges to participants that they can navigate more easily alongside an experienced advocate, such as a VPP. Likewise, HVIP transportation costs include an average of four round trips to external service appointments per participant and their VPP, plus a trip home from the hospital and at least one home visit from an HVIP staff member. Participants often receive public transportation stipends, and staff members receive mileage reimbursement, though programs can alter this with the costing tool. 

Crisis support resources

Key to HVIP crisis intervention is helping ensure that survivors can return to a safe and stable environment when they leave the hospital. For many, this is not a given, and the financial and logistical burden of navigating this alone presents yet another challenge. Needs vary by individual, but often entail temporary housing, food, clothes, and hygiene packs—all of which are included in this costing example. Sometimes VPPs will use petty cash and reimbursements to assist with these expenses, and other times they may have access to stipends, gift cards, or prepared packages. Grants providing discretionary funding flexibility are vital in supporting this component of the work. In recognition of the deep need for immediate cash assistance that many violent injury survivors face, some programs may choose to dramatically increase their investment in crisis support resources. The costing tool allows users to set the specific crisis support resources most appropriate for their target population and the percentage of participants expected to use each one.²⁰Access the customizable costing tool at the end of this report.

Operations

An HVIP’s operations costs are limited to technical assistance fees and office supplies—such as laptops or tablets, case management software, desks and chairs for staff and group therapy sessions, a printer and paper, pens and pencils, and uniforms. Technical assistance fees are included in year one of this example and support program-, capacity-, relationship-, and sustainability-building. The hospital frequently provides in-kind office space. Equipment costs account for initial purchases in year one, then for wear, tear, loss, and breakage in years two and three.

Key Takeaways and Considerations

Collectively, HVIPs are estimated to cost just under $1.1 million to support an average of 100 violent injury survivors annually. The largest budget category is staff (80 percent), with each remaining direct cost category accounting for less than 5 percent of the program’s overall costs. Notably, over half of the staff budget supports frontline workers—those providing violence intervention and counseling support directly to participants. Competitive salaries and benefit packages for these staffers are vital, given the unique experiences and skill sets required, and the often dangerous and traumatic job tasks they perform.²¹David M. Hureau et al., “Exposure to Gun Violence among the Population of Chicago Community Violence Interventionists,” Science Advances 8, no. 51 (December 23, 2022): eabq7027, https://doi.org/10.1126/sciadv.abq7027; Urban Peace Institute, “LA Peace Plan.” Of the estimated $10,798 cost per participant, crisis support accounts for just $302—or 3 percent. Crisis support funds are often discretionary, as they vary based on individual participant needs, but temporary and immediate access to food, housing, and hygiene-related necessities receive the most funding within this category. Finally, while the process of developing and implementing an HVIP is quite extensive, upfront costs typically include just first-time equipment, technical assistance, and accreditation courses, with the overall program budget increasing by just 4 percent over three years of implementation.

Gun assaults occur at high rates in cities, with stark human and financial costs. Reinjury rates among gun violence survivors are high,²²Ali Rowhani-Rahbar et al., “Firearm-Related Hospitalization and Risk for Subsequent Violent Injury;” Veronica A. Pear et al., “Risk Factors for Assaultive Reinjury and Death Following a Nonfatal Firearm Assault Injury: A Population-Based Retrospective Cohort Study,” Preventive Medicine 139, no. 3 (October 2020): 106198, https://doi.org/10.1016/j.ypmed.2020.106198. making this population a strong fit for community violence intervention programs. For nearly 30 years, many HVIPs have reduced reinjury and recidivism rates by immediately connecting survivors with VPPs at their hospital bedsides and, in the months that follow, providing survivors with services that directly address the social determinants of gun violence.²³The Health Alliance for Violence Intervention, “The HAVI: Healing Systemic and Interpersonal Violence.” This promising community violence intervention strategy is delivered at a fraction of the cost of gun homicides. Equipped with the knowledge of their key costs and components, more cities can take steps toward successfully implementing HVIPs.

Customizable Costing Tool