'Wraparound' support stops revolving door of violent injuries

Darius Irvin grew up in violent neighborhoods in Oakland and San Francisco. Nearly three years ago, he was rushed to the San Francisco General Hospital’s emergency department with nine gunshot wounds.

Irvin survived what was his third shooting in a little more than three years. He still visits the hospital. Not as a patient, but as a mentor counseling at-risk youth to avoid guns and gangs. The hospital’s “Wraparound” violence-intervention program has helped keep the 26-year-old Irvin and other former victims of gun violence out of the line of fire. 

Today, Irvin is a sophomore at San Francisco State College – and he credits the hospital’s outreach for helping him navigate his way toward a more stable and productive life. 

“I’ve got a lot of love in my heart for the hospital and for Wraparound,” he says. “They showed me I had a chance of being someone.”

Since its inception in 2006, the program has provided some 750 clients with ‘wraparound” support like mentorship, job training, assistance with court advocacy, transfer to safer schools and connections to mental health services.

After the doctors finished stitching patients’ wounds, case managers visit them at the bedside. Case managers come from the same communities as their clients and share similar experiences.

They start a conversation … mostly small talk at first. In Irvin’s case, it was about his love for Popeye’s chicken. Later, case managers assess the victim’s background and provide customized therapy for up to six months in partnership with a range of community-based organizations. 

Case manager Mike Tejada intervened with Irvin as he woke up in the hospital and realized he was still alive. Tejada has been a Wraparound case manager for nearly 11 years – motivated in part by the fact that five family members succumbed to gun violence over a two-year period.

“We call it the teachable moment,” Tejada says of the bedside intervention. “There is no negativity at that point. We focus on the positive things, starting with the fact that they survived. You take them by the hand and let them know of their own potential.”

Gun violence is responsible for more than 33,000 deaths and 84,000 injuries a year, according to the Centers for Disease Control and Prevention. While many victims don’t make it to a hospital alive or die before getting discharged, others survive and go back into violent neighborhoods where they are reinjured or killed, often in retaliation or from continued criminal activity.

The days the patient is in the hospital and away from the streets and their friends “is when they are open and vulnerable to making changes,” says trauma surgeon Rochelle Dicker. She founded Wraparound after repairing one youth’s gunshot wounds, only to see him readmitted a month later.

The program, which has treated patients from ages 10 to 30, has shown positive results.

For example, the return visit rate for violent injuries at the hospital has fallen from 16% to 4.5%, and Dicker says studies show it results in annual savings of $2.6 million in direct medical costs.

Her biggest reward is “not just that we are sending people out of the hospital alive. They are actually thriving because they get the support they deserve.”   

Dicker says hospitals and health systems need to address gun violence in their communities as a public health issue, like they would treat a chronic illness. “Diseases have risk and preventive factors, and violent injury is no different,” she says.

Programs like Wraparound are expanding across the country as more hospitals and health systems recognize the importance of applying public health interventions to curb gun violence in their communities.

For instance, Boston-based Brigham and Women’s Hospital (BWH) launched a violence-intervention program six years ago, partly in response to statistics showing violence to be the city’s leading cause of death for black and Latino males between ages 15 and 35.

At BWH, “violence recovery” advocates work with about 125 patients a year. They talk about the events that led to the violence, and set up safety plans to help keep patients safe as they transition back into the community. Advocates reach out to support groups and attend court hearings, housing appointments and job interviews with patients.

“We have to come at this from a different framework,” says program director Mardi Chadwick. “Instead of asking, ‘what is wrong with you, ask what has happened to you,’ and see trauma through the eyes of the victim.” 

Seattle’s Harborview Medical Center last year started a gun violence-intervention project modeled on a screening and counseling program for alcohol abuse it developed in the mid-1990s. After medical staff treat patients’ gunshot wounds, social workers interview them and brainstorm reasons to avoid high-risk behaviors. They meet with victims’ families and analyze the role of guns in victims’ lives over 12 sessions, developing strategies for anger management and resolving conflict.

When patients leave the hospital, case managers follow their progress over six months. They meet with local community agencies a few times each month to determine what nonmedical services can aid in the intervention.  

“We need to be more involved with prevention, in addition to just treating their immediate problem,” says project director Ali Rowhani-Rahbar, M.D. “When patients are in the hospital, we are at a critical point in their lives where we can intervene and hopefully begin to make a difference.”

Back in San Francisco, gunshot survivor Irvin hopes he can make a difference by counseling other victims of violence at the hospital and in the community.

“If I save four or five lives, that would be powerful,” he says.

Learn more about how hospitals and health systems are combatting violence in their communities at the AHA’s “Hospitals Against Violence” page.