Hospital-Based Violence Intervention – Ashley Xavier

Ashley Xavier

The people who work in hospitals, they want people to be healthier, they want to care for people, and then that person's discharged, and clinical providers may be like I hope they don't come back. I hope, you know, maybe I can see them in a grocery store, but I don't ever want to see them in this bed again. And then, unfortunately, sometimes that cycle may repeat itself, and it often would end up in someone's life being lost, and that was hard, and it left people wondering, is there more we can do? And that's really where HVIPs came in. You know, they are the more they are breaking a cycle that was really heartbreaking and really tragic. There was a 40% re injury rate before 40% of people were coming back with injuries, and now with our HVIPs, we're seeing a 3% re injury rate. I think that's just amazing. It's astounding. It's awesome.

Bobby Doyle

Welcome to solving gun violence, a student led podcast from the University of Virginia's gun violence solutions project, which is dedicated to finding effective strategies to combat one of America's most urgent issues, gun violence. Each of our episodes features experts sharing actionable solutions to improve community safety while upholding individual rights. In today's episode, Bobby Doyle, the director of UVA is gun violence solutions project, sits down with our very special guest, Ashley Xavier. Ashley is the director of Violence Intervention initiatives for the Virginia Hospital and Healthcare Association Foundation, where she leads a statewide strategy to strengthen and expand hospital based violence intervention programs, or HVIPs, across Virginia. With over a decade of experience working in and alongside hospitals, Ashley has built a career at the intersection of healthcare, public health and violence prevention. She has played a key role in expanding Virginia's HVIP infrastructure, securing significant federal, state and private investments, while also guiding a collaborative that now spans 10 health systems and 12 hospital based programs. Ashley also serves as HAVI training faculty, supporting practitioners nationwide and championing the belief that violence is a healthcare issue.

Bobby Doyle

Ashley, thank you so much for being here.

Ashley Xavier

Thank you again for inviting me. This is exciting.

Bobby Doyle

Of course, I'm really appreciative you're here, especially because we have not been able to focus as much on hospital based violence and adventure programs or HVIPs yet. And I'd love for you to get us started with just describing what is an HVIP, which is the acronym we'll use probably for most of this conversation.

Ashley Xavier

Yeah, again, I'm super excited. I mean, I love HVIPs. I love having spent the last, like several years of my working life working on them, so I appreciate the opportunity to talk about them. But really what HVIPs are, they are hospital based violence intervention programs, and they are a very successful national model that we have been able to adapt also very successfully here in Virginia with federal and state support. You know, our programs, we've seen a huge drop in patients returning with violent injuries. Our current estimated re injury for our service patients that receive our services is about 3% and in some areas of the country, re injury rates can be as high as 40% without some sort of intervention. So our programs, you know, we're not only saving healthcare costs, we're making our communities healthier and safer. Because violent injury doesn't just impact our patient. It echoes out to our families, to their friends, neighborhoods. It can just really have far reaching consequences, but really at the core of what makes us so successful, and I think really makes the H fit model so unique, is our Violence Intervention Specialists. These are staff members. They come from Virginia communities that experience high rates of violence. You know, they may have experienced violence themselves. They may have a family member who has experienced violence, but really what they do is that they use this shared experience and this background to connect with patients. While they're admitted, they earn their trust. They learn more about patients, what their lives are like before, what maybe they were working towards. Because regardless of whether it's a violent injury or some other health outcome, 80% of how healthy we are likely to be are really dictated by where we live, whether it's access to good, healthy, food, transportation, education, recreation spaces, all of this impacts our ability to make healthy choices. So our HVIPs, after they've met with patients, and they built their trust, and they built that really great rapport. They explore these individual health outcomes, these surroundings, work with patients to see what resources they may have access to to help them reclaim control of their lives. And they really work hand in hand with our H VIP staff.

Bobby Doyle

Thank you, and I'm really glad you mentioned the ripple effect of. Of these programs, right? They're so focused, like they are primarily focused on the patient in the hospital. And I'm excited later to get into what, what that means for the people around the folks who actually are treated. Now, one of the reasons I'm excited to talk to you about HPs is that there are great violence intervention specialists, as you mentioned around prevention professionals. There's different terms for the people who are actually doing the bedside work, but you have a slightly different role in this at the Virginia Hospital Healthcare Association. Could you explain how, in a role like that, you actually work with HVIPs? So I don't know if that's intuitive to everybody who thinks about like could think about work like that?

Ashley Xavier

No, yeah, I think this is a great question, because I'm not sure it isn't always intuitive. You know, it's funny when I tell people I work for VHHA, they're like, Huh? So really, what we are? We are a statewide nonprofit representing hospitals across the Commonwealth. This includes 26 health systems, 117 individual hospitals, and on this side, you know, in a lot of ways, this role is kind of administrative, but We're incredibly fortunate to partner and support our member hospitals as we work together to make Virginia the healthiest day in the nation. Each of our hospitals, each of our members, they serve a very unique and distinct community. These communities have their own health needs, their own health priorities, and for some of our communities, that means experiencing higher rates of violence, and that's where our A chips really come in. Violent injury can have a really serious impact on our overall health, overall well being our individuals, of our communities, and by addressing and preventing violence at our hospitals, you know, they're really taking that step toward their mission of providing high quality, individualized care, our mission of making Virginia and all of our people so much healthier. And for me, personally, injury prevention and safety has been a passion for a long time like I can I can think back to my undergrad degree in a psychology course. So even before I ever started working for hospitals or with the hospital association, so I just, in a lot of ways, I feel very fortunate and lucky that I get to work with the Association, work with organizations that we all share the same goal and get to work at the statewide level. Work with our each, each of our hospitals, as they adapt this model to their unique system and the unique needs, and we're producing some really, really amazing outcomes. And I just love getting to travel the state, going to each of our HVIPs and just watching lives change.

Bobby Doyle

Yeah, it's pretty remarkable. The network of HVIPs that Virginia has been able to establish, it's not assumed that we would have a dozen HVIPs across the state right now. One of the things that I think is helpful, at least was really helpful for me to understand these programs was understanding that H strips are serving patients that come in with penetrative injuries. And I know some people might assume that you show up with a gunshot wound in hospital, and you're going to get all the care in the world, and all the needs you might have will be met by what already is existing through social work and all the other clinical specialties in the hospital. Could you talk about how they fit programs really are creating this big impact that you've already alluded to? And if you could do that by describing the pathway a patient takes through coming in, in the emergency department to when they're discharged is, I think, when I was first learning about these programs, that's what really helped me understand where the impact was happening.

Ashley Xavier

Yeah, absolutely. So kind of, as you alluded to, it does start age fit work always starts with clinical care. You know, in Virginia, we're so fortunate. We have really incredible, talented and passionate clinical providers on our trauma care and emergency teams. You know, this includes surgeons, radiologists, anesthesiologists, paramedics, so many different types of nurses, whether it's critical care or emergency forensics, but there's just so many people that are involved in making sure that our violently injured patients receive the treatment that they need, because this is life saving treatment. I think one thing that really struck me is that when someone arrives at a Virginia Hospital with a violent injury or a penetrative injury, there's a 90% chance that they will survive their injury. And I think that's just a real testament to what clinical care can do, but it also shows why hfps are so vital, you know, so first we have to get the patient's physical injuries treated and stabilized. But our a trip staff aren't just, you know, waiting for that to happen, they are engaging with the family and friends who may have showed up for their loved one. Do they have what they need? I mean, as we noted before, traumatic injury ripples, do they need any food and water? Were they able to park? Do they have access to a phone? Do they need a charger? Have they connected with the clinical team? Or have they been able to get an update? And then our age of is also connecting with the clinical team. What is this patient's, you know, treatment looking like? Are they going to go up to the or are they, you know, potentially going to be intubated for a little while? So that's where everything starts. Everything starts with clinical care, connecting with the family, connecting with the clinical team. Because this is, this is a comprehensive model. This is a wraparound model. This has so many touch points, which is one part of what makes it so successful. So, you know, that's that starts the groundwork. But eventually the HVIPs will meet with the patient. And this the hospital admission is really where HVIPs work is just getting started. You know, this is where the bulk of the clinical care is going to happen, and some will happen after discharge. But for H trips, this is where they get started. So you know, HVIPs have done a lot of this, front loaded work with family, making sure they have what they need, making sure that they're in a good position to care for their loved one, connecting with the clinical team to see what their care plan may look like. How long are they going to be in the hospital? You know, when and where are they going to get discharged? So they have this great foundation, and they bring this foundation to the patient when the patient's in a good position to be met with. But patients can sometimes be hesitant to meet with HVIP staff. You know, they've just had a really big trauma. They may have come out of surgery, it could be really disorienting. You know, their whole life has changed in a lot of ways. So sometimes an hvap staff member may go to a room even with all these innate skills that they have, and a patient might be like, this is a lot for me right now. I need to give me a little bit to process. An HVIP person will come the next day, you know, meet with them, just build rapport. A lot of times, talking about things that are way beyond, or not way beyond, having nothing to do with what brought them into the hospital. They could be talking sports, weather, video games, you know, and that. And then on the next day, they'll come again, and maybe that's when they really delve into what the hfip services are trying to get that. Yeah, I'm interested in learning more. You know, let's connect again once you've been discharged. Because this was a statistic that I saw recently when looking at our data. 87% of HVIP work is outside of the hospital. So they are just laying the groundwork so that when they're discharged, you know, they have that follow up phone call set up, and that's where they start to really get into the conversation around, you know, what does their life look like? Is your housing stable? How is your employment? You know, are you caring for anybody? So, you know, in the hospital, the hospital is just setting the groundwork, and then they, our age of staff, really take it from there.

Bobby Doyle

Yeah, my understanding for these programs is that the work you do after discharge is often the special sauce, but you need to have that relationship set up to be able to do that, but with so much retaliation and readmission for folks who show up with a penetrative injury, that post discharge support can be really huge. I know for changing outcomes you've talked about a little bit, but I'd love for you to dive into any more details you can provide about what, what does it mean to like, support someone after the discharge? Like, is it helping them navigate services? Is it providing them resources yourself? Like, what are these programs do for folks after they're discharged from the hospital? And how does that impact these things that you're talking about.

Ashley Xavier

So ultimately, HVIPs and there's our staff, and our model is about empowering patients. So we're not doing things for the patients. We're working with them. We are building what we like to call an individual service plan. So that comes from talking with the patients, identifying what their goals are. If you want to get your GED, you know, that could be the big goal, and then you're gonna have little goals underneath it, finding a GED program, finding out what it costs. How are you going to get there? And that's where, you know, that's where the HVIP come in, is that they'll be like, okay, patient is going to do X, Y and Z, and then our HVIP staff will do A, B and C. So maybe it could be our patient's going to get their GED. They're going to research how to get it, how they need to get there, and then our H fit will provide the funding for them to register, or maybe for the cost of the test. You know, maybe we will provide some Uber gift cards if they need assistance with transportation. So I think that's probably a good example of one ways, is that it's we're empowering patients, because our interactions with them may be only six months to a year, and then they're going to be more independent. They're going to be taking control of their life. They're going to know how they can be healthier, how to hopefully never be in a situation where they are injured again, you know, they might be connected with other community partners who are going to pick up the case from us. Because ultimately, this, this is a many person involved kind of process.

Bobby Doyle

Yeah, talking with folks who work within hospitals, but also like out of community with those i. There's such a team based approach, and everyone really does acknowledge like the team work that takes, but ultimately, we're trying to help support someone to kind of be self sufficient and stand up on their own two feet, which is what people want to do. Right? It's not like folks want to be in a situation where they are feeling like their need are hurting. I'm someone, I think most people are folks who respond well to stories and like examples, and I with respecting privacy and everything like that, I would love to hear an example of, like a patient or just something that sticks with you from like an H step program, specifically, if there's something you could share with our listeners.

Ashley Xavier

Yeah. And to your point about storytelling, I think this is a great question, and I love this question, but not because I necessarily have a specific patient story, but more because I think about what care looked like that inspired these kind of programs. So like what our traditional kind of trauma and clinical care looked like. So traditionally, patients, as we notable for, you know, and still, now they're going to be brought to the hospital with their injuries. They're going to receive some really amazing clinical care. They're going to be discharged. But that was kind of it. We didn't have that specific focus on social emotional needs. It was really about the physical needs. And sometimes that first touch point with the hospital with the hospital with a violent injury might be something more minor, you know, maybe they go to the ED, they receive treatment in the ED, and then they're discharged from the ED. But often, you know, it could be weeks or months later that person might return, and it might be a more severe injury that's going to require more care, more expertise, more care and compassion from our caregivers. Because people who work in hospitals, they want people to be healthier, they want to care for people. They pour all this energy and education into, like, providing really amazing physical care, and then that person's discharged, and clinical providers may be like, I'm under I hope. I hope. I hope I don't. I hope they don't come back. I hope, you know, maybe I can see them in a grocery store, but I don't ever want to see them in this bed again, because it's heartbreaking and that can wear on you. And then, unfortunately, sometimes that cycle may repeat itself, and it often would end up in someone's life being lost, and then a care provider who just, you know, they met this person, they got to know this person, and then, and then they're gone. And that was hard, and it left people wondering, is there more we can do? And that's really where hfips came in. You know, they are, the more they are, breaking a cycle that was really heartbreaking and really tragic, and over and since 2019, since our first grant, over 9000 Virginia's have received these HVIP services. They've seen this cycle change and be broken. You know, saving lives, saving saving millions of dollars, making communities healthier and safer.

Bobby Doyle

And I just want to put that 9000 kind of patient number in context we in Virginia see on average, from like 400 to 500 or so homicides a year right now. And so when you think about how many people are being killed, often through firearms and penetrative injuries, and the number of patients that these sort of programs are seeing. There's a real scale that we're able to hit across all these hospitals that really is starting to get at these like numbers of injuries and deaths that really do not need to be occurring.

Ashley Xavier

Yeah, I think Yeah. And I think I noted before, you know, there was a 40% re injury rate before. That's what you know you would see in that heartbreaking cycle, is 40% of people were coming back with injuries, and now, with our H FIPS, we're seeing a 3% re injury rate. I think that's just amazing. It's astounding. It's awesome.

Bobby Doyle

Yeah, I want to ask next about, well, not having people show up for injury and how much healthcare workers really care about that really speaks to my experience. As well as a first responder, we have the term frequent flyers for folks that you see over and over again, and there is a frustration as a medical provider in some way, when you can help patch someone up, you can help support them in an emergency situation, but you can't change that underlying circumstance that makes them show up again and again and have to treat them again and again. And it's very I mean, we talk people talk a lot about burnout in the healthcare field, and one of the ways people burn out is by feeling like the care they're providing really isn't ultimately changing the things that are like. It's just kind of pushing a boulder up a hill that's rolling back down and again again. So just on that level, HVIP programs, I'm sure, are helping people feel a little more connected to the care they're giving, rather than feeling Sisyphean.

Ashley Xavier

Absolutely, it's stories. It's an anecdotes. But I've heard when I get to go visit our HVIP's, I like. Connect with nursing staff who are like, this is awesome. Now I know that somebody has someone who's going to follow them afterwards, help them live a healthier life, help them get the resources they need. I really do think it helps contribute to preventing burnout with our clinical providers who want to be able to do more, but they're already so busy with just providing the clinical care. You know, they're it's a lot.

Bobby Doyle

Yeah, I mean, these are hard cases. I mean, penetrative injuries are hard to deal with as a clinical provider. You mentioned burnout. Everyone at the hospital is has some level of certification or training. It is really like a certification and training based industry for the most part. And I'm curious what sort of support professional development training do folks in these roles get, and how does how does that inform how they approach their roles?

Ashley Xavier

Yeah, I mean, as you noted, training is so important, it really like can really set us up for success, and our programs are designed very intentionally with the needs of staff in mind. You know, our staff, our hfip staff, are critical to hvik success. We want them to be well trained. We want them to feel supported. We want them to have good connections with their peers. So with our grant funds, we've invested in a lot of different training and opportunities and providers, you know, a big one being our partnership with the VCU injury and violence prevention program. You know, I started there. They provide specialized training on their bridge in the gap model. They're based in Virginia, so they know what Virginia looks like, how we might be different from other states. They're able to do in person, visits with our with our hospitals, whether it's going there or bringing them to VCU to shadow, even us at the association. You know, we, I like to call us a funder with an asterisk, because we remain so engaged the whole time. We provide our own opportunities for our H ships to connect with each other. I mean, we call ourselves the Virginia HVIP collaborative. We host virtual meetings. We host meetings at our Richmond office way where we'll, you know, do networking, provide food, provide education. We include funding and encourage hfips to go to or national conferences that in person, connection is so important in this work, and that's really what prevents the burnout and connecting with people nationally, is you can see what they're doing successfully, and how can we bring that back here and make ourselves more successful? So not only you know, our conferences opportunities to get a reprieve from the day to day and connect with peers, it's also an opportunity to bring back new knowledge to make us successful. And I do think it's a huge part of why we are successful is because we're constantly looking at what else is out there. How can we do better? How can we improve? Because broadly, with the span of time, the H fit model is very new. Some of our oldest age HVIPs in the country are not even 30 years old yet. I mean, we've only been funding programs since 2019 but it's just growing leaps and bounds.

Bobby Doyle

To your point about these programs being very new, we're a podcast based at a university very interested in evidence, and there is evidence for effectiveness of HS, but it's newer, it's thinner, and we really want to know more about how these programs can be as effective as possible, serve patients as well as they possibly can. This is something we're working at at UVA. I know you and partners at VCU and other places are working on it. I would love to hear, and this doesn't have to be a like RCT backed like citing studies. Answer, I would love to hear, as someone who's worked with many of these programs, you've seen what can make them strong? What sort of things do you look for in like a strong hospital based violence intervention program? What sort of things really do you think is the secret sauce, or the things that can really make them so effective?

Ashley Xavier

Yeah, fantastic question. So I think our most successful programs really represent critical link, linkages between hospitals and their communities. Our most successful programs have strong community partnerships. You know, we can see in these communities the lives that they've been changed, and that success has translated into, as you noted, we have 12 different programs. These programs are serving urban. Urban, rural communities. We have programs that kind of cover every corner of the Commonwealth. We have a program in southwest we have programs that dot along i 64 programs out on Hampton Roads, Northern Virginia, South Side. And it's because our programs are that linkage between hospitals and communities, and it's resulted in us being able to continue to get federal and state support to the tune of $20 million so we've seen that success just go from our first four or five programs in 2019 to now the 12 programs we have now, on top of that, hfip staff, they have a shared background and experience with the people that they are with our with our patients who have violent injury. It kind of contributes like an IT factor that our hfip staff just have innately within them that makes it so that they can gain that trust and respect of patients, like I said, maybe it's not there on the first day, but there's something there that when they come back on the second day, the patient's like, I see something here.

Bobby Doyle

I that that expression really sits well with me, of like, linking the hospital community, because, as we've talked about already, there's a foundation built within the hospital when they're admitted. But it really is that kind of community linkage that these programs, where these is where these programs shine. I've heard from many people who've worked with these programs, are familiar with these programs, that the frontline workers are really what can make or break, like the effectiveness and to be effective, it and like as a frontline worker, to be like a top tier one, it is such an incredibly complex alchemy of qualities that you have to have between me being very empathetic and patient and understanding of how people are approaching you, and also having all these life experiences that can connect You with that person and being able to navigate a healthcare system, which is often hard to navigate. So it's a, it's quite a challenging situation to be put in, but those are from my kind of anecdotal experience. What can really help drive these programs? Here's a here's a broader question you have. You have a lot of familiarity through this. And I work with fire and violence generally, the victims that like come through programs of fire and violence penetrated injury. Is there anything that you feel like people misunderstand about, like, what this how this problem presents, are the ways in which we can tackle it or that you wish they knew more about?

Ashley Xavier

Yeah, I mean, anytime anyone is impacted by violence, it's tragic, whether it's community violence or domestic violence, it's not it's not just physical. It can leave scars that are emotional and social. It goes far beyond just patients. It can change how families and communities see themselves, how they function, you know, how they feel safe. So I think, I think that's why our H FIPS have been so successful, because we recognize that violence doesn't just leave physical impacts, it leaves emotional and social. We provide customized support to patients that recognize that we pull in their entire support support system. You know, especially when we if we have like, a teen or youth. How's mom doing? You know, does mom need some sort of support? Does she need a referral? You know? How are their communities doing? Do we have a partner somewhere who maybe can come to this person's neighborhood and to kind of help them process it as a community? And we've just, we've, we've had so much support that has recognized this success. I have loved seeing these stories shared in news media in awareness days. You know, October is Domestic Violence Awareness Month. A lot of our hospitals host an event. Then in June, we have wear orange day. And even just this opportunity to talk about HVIPs, I think it's a great way to kind of share how violence is not just physical.

Bobby Doyle

I'm going to move to our final question, which is our impossibly big question we ask all of our guests, and we'll see how much longer we ask people this. But for now, it's still, I think, an interesting one to ask, because what do you do with a question like this? But Ashley, what is the solution to the gun violence epidemic look like to you?

Ashley Xavier

So for HVIPS, we serve all types of violence, you know, and some of it's going to be physical violence. Um. It could the physical penetrative injury. Could be from a firearm. It could have been a stabbing. You know, for domestic violence survivors, sometimes it might not show up physically. It might show up as emotional abuse, verbal abuse. But what I think has made our H FIPS so successful on, you know, maybe not being a solution, but definitely improving outcomes, is that we recognize that 80% of someone's health outcomes is dictated by the zip code they live in. You know, like as we noted before. So our H FIPS, we meet people where they are, we help them identify what their strengths are. It's not just about what are you lacking, what do you what do you have that's going to help you be successful? What's in your community that's going to help you be successful? How can we augment that? How can we help you build on that, so that when this your service plan is done, and you've graduated from our services, you are on a really good trajectory, a really good trajectory. Any of this looks different for everyone. You know, as I noted before, with the example of the GED, it could also include, you know, finding stable housing, securing a better job, finding a mental health provider. You know, we really customize the services to each person and build them a plan that's unique to them, and I think that's ultimately how we're going to improve violence, is meeting people where they are providing services that are customizable to them.

Bobby Doyle

Thank you so much for joining us today. Where can people find you oline?

Ashley Xavier

Yeah. Probably the best spot to go first would be the VHHA website. And we have a foundation page. In hopefully in a month or so we will have a webpage our foundation page that will highlight the great work of our HVIPs.

Bobby Doyle

That is our episode for today. For more info about Ashley's work please see the links in the bio. For more info about the GVSP go to gvsp.virginia.edu. Make sure to follow the show to get updates for future episodes. We'll see you next time.