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.

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.

Hospital-based violence intervention: risk reduction resources that are essential for success.

INTRODUCTION: Hospital-based violence intervention programs (VIPs) aim to reduce violent injury and recidivism. The aim of this study was to determine the most significant risk reduction variables associated with success in our VIP. We hypothesized that our recidivism rate declined since VIP's inception and that we could identify risk reduction variables that were independent determinants of program success. METHODS: We analyzed our prospectively collected data for 2005-2011 from our VIP database. Success was defined as more than 50% needs met without recidivism or attrition. Impact and outcome evaluation was performed per a model promoted by the Centers for Disease Control. Rates of risk reduction and injury recidivism were calculated. Case management time spent per client (dose) was defined as low (0-1 hours per week), medium (1-3 hours per week), moderate (3-6 hours per week), and high (>6 hours per week). Correlation coefficients and logistic regression were used to examine associations between variables and success in the VIP. RESULTS: Two hundred fifty-four clients received services. Meeting needs in mental health (odds ratio, 5.97; 95% confidence interval, 2.72-13.07) and employment (odds ratio, 4.41:95% confidence interval, 1.56-12.46) proved significantly associated with success (p < 0.005). The 6-year program recidivism rate was 4% versus historical control of 16% (p < 0.05). Moderate and high exposure to intensive case management in the first 3 months was also significantly associated with success (p < 0.05). Success in our VIP was not associated with age, gender, education level, previous incarceration, probation status, or length of time in program. DISCUSSION: For 6 years, our recidivism rate has decreased fourfold compared with the rate before VIP inception. For startup and maintenance of a VIP, it is essential to know where to focus collaborative efforts in communities to target the most critical risk reduction resources. This study provides guidance-securing mental health care and employment for our clients appears to be predictive of success. The value of early "high-dose" intensive case management is also essential for reducing recidivism. LEVEL OF EVIDENCE: Care management study, level III.