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New research from the CIC and partners shows that when hospitals have a post-discharge care team (PDCT) dedicated to working with survivors of gun violence after discharge from the hospital, survivors are:

• More likely to show up at follow up outpatient appointments.
• Less likely to visit a hospital emergency department for issues that the care team can help navigate.
• Likely to be in the hospital fewer days if they need to be readmitted.
• Overall, the PDCT saves health care systems money, mostly due to reduced hospital readmission length of stay.

The PDCT in this study was implemented as a pilot randomized controlled trial to provide a resource for patients from the time they were admitted to the hospital to the time they returned to an outpatient clinic for follow up – usually around 10 days - and as needed after return to clinic . In this study, the PDCT was comprised of a dedicated nurse navigator and a medical social worker.

Post-Discharge Care Team Roles

During the gun violence survivor’s hospital stay, the nurse navigator provided education to the patients on their specific injury, wound care needs, medication regimen, pain management strategies, and plans for follow up care. The nurse navigator also provided a unique phone number that patients could call directly with questions, and they also followed up by phone with patients within 48 hours and at one month after discharge, as well as additional phone calls on an as needed basis.

The medical social worker worked with the patients to evaluate concerns with substance use, community safety, finances, employment, family support, legal issues, management of chronic pain, and mental health. They also helped patients set up transportation to appointments, connected them with needed financial resources, including the Crime Victim Compensation Program, and worked with the hospital violence interruption program to coordinate resource referrals and connections with emergency housing resources if the patient had safety concerns upon returning to the community.

Both team members met with the patients during their in-person visits to the for follow up care. This allowed them to follow up on patient progress, provide additional needed resources, and act as a bridge between the patient and the care team.

Future Directions

The findings from this study show that post-discharge care teams benefit survivors of gun violence and health care systems in comparison to gun violence survivors not enrolled in the program. Future work should focus on expanding this model to high-risk patient groups who are survivors of firearm violence and other types of traumatic injury.

Read the complete study in The Journal of Trauma and Acute Care Surgery: .

Study Team Members

• Elise Biesboer, MD
• Amber Brandolino, MS
• Ashley Servi, DNP
• Becca Laszkiewicz, MSN, RN
• Liza Herbst, MSW
• Susan Cronn, DNP
• Jennifer Cadman, MSN
• Colleen Trevino, PhD
• Mary E. Shroeder, MD