Dicker Rochelle A, Jaeger Sebastian, Knudson Mary M, Mackersie Robert C, Morabito Diane J, Antezana Javier, Texada Michael
Department of Surgery, University of California-San Francisco and Division of Acute Care Surgery, San Francisco General Hospital, San Francisco, California, USA.
J Trauma. 2009 Dec;67(6):1169-75. doi: 10.1097/TA.0b013e3181bdb78a.
The severity and disparity of interpersonal violent injury is staggering. Fifty-three per 100,000 African Americans (AA) die of homicide yearly, 20 per 100,000 in Latinos, whereas the rate is 3 per 100,000 in Caucasians. With the ultimate goal of reducing injury recidivism, which now stands at 35% to 50%, we have designed and implemented a hospital-based, case-managed violence prevention program uniquely applicable to trauma centers. The Wraparound Project (WP) seizes the "teachable moment" after injury to implement culturally competent case management (CM) and shepherd clients through risk reduction resources with city and community partners. The purpose of this study was to perform a detailed intermediate evaluation of this multi-modal violence prevention program. We hypothesized that this evaluation would demonstrate feasibility and early programmatic efficacy. We looked to identify areas of programmatic weakness that, if corrected, could strengthen the project and enhance its effectiveness.
We performed intermediate evaluation on the 18-month-old program. We selected the Centers for Disease Control and Prevention-recommended instrument used for unintentional injury prevention programs and applied it to the WP. The four sequential stages in this methodology are formative, process, impact, and outcome. To test feasibility of WP, we used process evaluation. To evaluate intermediate goals of risk reduction and early efficacy, we used impact evaluation.
Four hundred thirty-five people met screening criteria. The two case managers were able to make contact and screen 73% of gun shot victims, and 57% of stab wound victims. Of those not seen, 48% were in the hospital for <or=2 days. Fifty-four percent of those screened had identified needs and received CM services. Thirteen percent refused services. Of the high-risk clients receiving full services (N = 45), 60% were AA and 30% were Latino. Sixty percent of the AA had no contact with their fathers. CM "dose": In the first 3 weeks of enrollment, 40% of the time, case managers spent >6 h/wk with the client. Forty-one percent of the time, they spent 3 hours to 6 hours. Seventeen of 18 people who required >6 hours had two to three needs. Attrition rate is only 4%. The table demonstrates percent success thus far in providing risk reduction resources.
WP case managers served high-risk clients by developing trust, credibility, and a risk reduction plan. Cultural competency has been vital. Six of seven major needs were successfully addressed at least 50% of the time. The value of reporting these results has led WP to gain credibility with municipal stakeholders, who have now agreed to fund a third CM position. Intermediate evaluation provided a framework in our effort to achieve the ultimate goal of reducing recidivism through culturally competent CM and risk factor modification.
人际暴力伤害的严重程度和差异令人震惊。每年每10万非裔美国人中有53人死于凶杀，拉丁裔为每10万中有20人，而白人为每10万中有3人。为了实现降低目前高达35%至50%的伤害累犯率这一最终目标，我们设计并实施了一项以医院为基础、由病例管理的暴力预防计划，该计划特别适用于创伤中心。环绕项目（WP）抓住受伤后的“可教时刻”，实施具有文化胜任力的病例管理（CM），并与城市和社区合作伙伴一起引导客户利用降低风险的资源。本研究的目的是对这个多模式暴力预防计划进行详细的中期评估。我们假设该评估将证明其可行性和早期项目效果。我们希望找出项目薄弱环节，若加以纠正，可加强该项目并提高其有效性。
我们对这个实施了18个月的项目进行中期评估。我们选择了疾病控制与预防中心推荐的用于预防意外伤害项目的工具，并将其应用于WP。该方法的四个连续阶段为形成性、过程性、影响性和结果性阶段。为测试WP的可行性，我们采用过程评估。为评估降低风险的中期目标和早期效果，我们采用影响评估。
435人符合筛查标准。两名病例管理员能够与73%的枪伤受害者和57%的刺伤受害者取得联系并进行筛查。在未接受筛查的人中，48%在医院停留时间≤2天。接受筛查的人中有54%已确定有需求并接受了CM服务。13%的人拒绝服务。在接受全面服务的高危客户（N = 45）中，60%是非裔美国人，30%是拉丁裔。60% 的非裔美国人与他们的父亲没有联系。CM“剂量”：在登记的前3周，40%的时间里，病例管理员每周与客户相处的时间超过6小时。41%的时间里，他们花费3至6小时。在18名需要超过6小时服务的人中，有17人有两到三个需求。流失率仅为4%。该表显示了到目前为止在提供降低风险资源方面的成功百分比。
WP的病例管理员通过建立信任、信誉和降低风险计划来服务高危客户。文化胜任力至关重要。七项主要需求中的六项至少在50%的时间里得到了成功解决。报告这些结果的价值使WP在市政利益相关者中赢得了信誉，他们现在已同意为第三个CM职位提供资金。中期评估为我们努力通过具有文化胜任力的CM和风险因素调整来实现降低累犯率的最终目标提供了一个框架。
