Designing an Information and Communications Technology Tool With and for Victims of Violence and Their Case Managers in San Francisco: Human-Centered Design Study.

BACKGROUND: Violence is a public health problem. Hospital-based violence intervention programs such as the San Francisco Wraparound Project (WAP) have been shown to reduce future violent injury. The WAP model employs culturally competent case managers who recruit and enroll violently injured patients as clients. Client acceptance of the WAP intervention is variable, and program success depends on streamlined, timely communication and access to resources. High rates of smartphone usage in populations who are at risk for violent reinjury create an opportunity to design a tailored information and communications technology (ICT) tool to support hospital-based violence intervention programs. OBJECTIVE: Current evidence shows that ICT tools developed in the health care space may not be successful in engaging vulnerable populations. The goal of this study was to use human-centered design methodology to identify the unique communication needs of the clients and case managers at WAP to design a mobile ICT. METHODS: We conducted 15 semi-structured interviews with users: clients, their friends and families, case managers, and other stakeholders in violence intervention and prevention. We used a human-centered design and general inductive approach to thematic analysis to identify themes in the qualitative data, which were extrapolated to insight statements and then reframed into design opportunities. Wireframes of potential mobile ICT app screens were developed to depict these opportunities. RESULTS: Thematic analysis revealed four main insights that were characterized by the opposing needs of our users. (1) A successful relationship is both professional and personal. Clients need this around the clock, but case managers can only support this while on the clock. (2) Communications need to feel personal, but they do not always need to be personalized. (3) Healing is a journey of skill development and lifestyle changes that must be acknowledged, monitored, and rewarded. (4) Social networks need to provide peer support for healing rather than peer pressure to propagate violence. These insights resulted in the following associated design opportunities: (1) Maximize personal connection while controlling access, (2) allow case managers to personalize automated client interactions, (3) hold clients accountable to progress and reward achievements, and (4) build a connected, yet confidential community. CONCLUSIONS: Human-centered design enabled us to identify unique insights and design opportunities that may inform the design of a novel and tailored mobile ICT tool for the WAP community.

"You don't want anyone who hasn't been through anything telling you what to do, because how do they know?": Qualitative analysis of case managers in a hospital-based violence intervention program.

STATEMENT OF PURPOSE: Intentional violent injury is a leading cause of disability and death among young adults in the United States. Hospital-based violence intervention programs (HVIPs), which strive to prevent re-injury through intensive case management, have emerged as a successful and cost-effective strategy to address this issue. Despite the importance of strong therapeutic relationships between clients and their case managers, specific case manager behaviors and attributes that drive the formation of these relationships have not been elucidated. METHODS: A qualitative analysis with a modified grounded theory approach was conducted to gain insight into what clients perceive to be crucial to the formation of a strong client-case manager relationship. Twenty-four semi-structured interviews were conducted with prior clients of our hospital's HVIP. The interviews were analyzed using constant comparison method for recurrent themes. RESULTS: Several key themes emerged from the interviews. Clients emphasized that their case managers must: 1) understand and relate to their sociocultural contexts, 2) navigate the initial in-hospital meeting to successfully create connection, 3) exhibit true compassion and care, 4) serve as role models, 5) act as portals of opportunity, and 6) engender mutual respect and pride. CONCLUSIONS: This study identifies key behaviors of case managers that facilitate the formation of strong therapeutic relationships at the different stages of client recovery. This study's findings emphasize the importance of case managers being culturally aligned with and embedded in their clients' communities. This work can provide a roadmap for case managers to form optimally effective relationships with clients.

Violent reinjury risk assessment instrument (VRRAI) for hospital-based violence intervention programs.

BACKGROUND: Violent injury is the second most common cause of death among 15- to 24-year olds in the US. Up to 58% of violently injured youth return to the hospital with a second violent injury. Hospital-based violence intervention programs (HVIPs) have been shown to reduce injury recidivism through intensive case management. However, no validated guidelines for risk assessment strategies in the HVIP setting have been reported. We aimed to use qualitative methods to investigate the key components of risk assessments employed by HVIP case managers and to propose a risk assessment model based on this qualitative analysis. MATERIALS AND METHODS: An established academic hospital-affiliated HVIP served as the nexus for this research. Thematic saturation was reached with 11 semi-structured interviews and two focus groups conducted with HVIP case managers and key informants identified through snowball sampling. Interactions were analyzed by a four-member team using Nvivo 10, employing the constant comparison method. Risk factors identified were used to create a set of models presented in two follow-up HVIP case managers and leadership focus groups. RESULTS: Eighteen key themes within seven domains (environment, identity, mental health, behavior, conflict, indicators of lower risk, and case management) and 141 potential risk factors for use in the risk assessment framework were identified. The most salient factors were incorporated into eight models that were presented to the HVIP case managers. A 29-item algorithmic structured professional judgment model was chosen. CONCLUSIONS: We identified four tiers of risk factors for violent reinjury that were incorporated into a proposed risk assessment instrument, VRRAI.

A decade of hospital-based violence intervention: Benefits and shortcomings.

INTRODUCTION: Initial analyses of hospital-based violence intervention programs (VIPs) have demonstrated decreased violent injury recidivism. Long-term VIP performance has not been assessed. Violence intervention program quality improvement requires evaluation to identify shortcomings and client subpopulations warranting additional resources. We evaluated our case manager-based VIPs to identify modifiable risk factors that most impact violent injury recidivism and determine subpopulations that need modification of targeted services. METHODS: Data on demographic variables, socioeconomic factors, needs, and injury recidivism from 2005 to 2014 were collected through our VIP database. Possible client needs included housing, education, employment, court advocacy, driver's license obtainment, and "other." Case managers assessed needs as "not needed," "identified (unmet)," and "met." χ And nonparametric tests were used to identify factors associated with recidivism reduction. RESULTS: Over the 10-year period, 466 clients were enrolled in VIP. During the program period, the violent reinjury rate was 4%, as compared with a historical control of 8% from 2000 to 2004. Women had lower rates of reinjury than men (3% vs 13%, respectively, p = 0.023). Blacks had the lowest recidivism (2%, p < 0.0001), whereas a higher rate (11%) was observed among Latinos. Although a minority of clients (5%), 100% of white clients were reinjured. Mental health services (51%), victim-of-crime compensation (48%), employment (36%), and housing (30%) were the most frequently identified needs. Expressing the need for education was significantly associated with likelihood of reinjury, an effect that was completely reversed when the need was met. CONCLUSION: This evaluation of a VIP demonstrates sustained recidivism reduction and success in addressing client needs from a traditionally underserved population. Efforts to identify and address root causes of Latino and white client reinjury should be increased. Violence intervention program prioritization of housing needs may reduce future reinjury. This study demonstrating sustainable success underscores the importance of increased integration of VIP into trauma centers nationally. LEVEL OF EVIDENCE: Therapeutic study, level III.