Wraparound Project Reduces Reinjury Rates From 16 to 4 Percent
From left, Javier Antezana, case manager; Ricardo Garcia-Acosta, case manager; Michael Texada, case manager; and Rochelle A. Dicker, MD, FACS, assistant professor of surgery and anesthesia, are the Wraparound Project team at the UCSF-affiliated San Francisco General Hospital and Trauma Center.
When Rochelle Dicker, MD, was a UCSF intern, she cared for a 16-year-old boy who had been shot as a result of gang violence. He was eventually discharged, but returned to the emergency room a few weeks later after he was shot again.
“It had a profound impact on me,” said Dicker, now a trauma surgeon at the UCSF-affilated San Francisco General Hospital and Trauma Center (SFGH). “I felt like I was seeing a societal cancer. Diseases have risk and preventive factors, and violent injury is no different. I decided that there was no better way to deal with this than to look at the risk factors for violence and figure out ways to deal with them.”
After completing her training, including fellowships in trauma, critical care and violence prevention, Dicker founded and now directs the Wraparound Project in 2006. One of the nation’s first hospital-based violence prevention programs, it seeks to close the revolving door of violent injury by seizing the “teachable moment” that many patients experience in the hospital.
“When someone goes through a life-threatening violent injury, oftentimes their response is, ‘I’m ready: I need to do something positive to change my life so this doesn’t occur again, but I just don’t know how,’” said Dicker.
The Wraparound Project has a team of three culturally competent case managers who grew up in the same communities as their clients. They establish trusting relationships with patients at the bedside, where they conduct an initial needs assessment.
They often start to break the cycle of violence in the SFGH parking lot, by talking with friends and relatives of the victim who might otherwise plan retaliation. After a patient is discharged, the case managers may make home visits, assist with court advocacy, and help participants find employment, transfer to safer schools, and connect with mental health services. Case managers can even arrange for youth to remove gang-related tattoos.
Recently, SFGH launched the Empowerment Center, a leadership academy designed to help selected Wraparound Project graduates build skills and become agents of positive change in their communities.
Rochelle Dicker, MD
By helping clients access community risk-reduction resources, the Wraparound Project has reduced reinjury rates from 16 percent to 4 percent. The program also saves money, since the average cost of caring for one youth victim of interpersonal violence is nearly $50,000, and more than 80 percent of victims are either uninsured or on public insurance programs such as Medi-Cal.
“Based on a recent cost analysis, we calculated that if the Wraparound Project expanded to reach every violently injured young person between 12 and 30 who came through our doors, it would result in an annual net savings of $2.6 million in direct medical costs,” said Dicker.
Dicker receives frequent inquiries from other hospitals across North America and has helped many trauma centers start similar programs. She and colleagues at other hospitals are advocating for national policy changes that would make such programs the standard of care at all Level I trauma centers, like SFGH, with high rates of violent injury.
“It is very clear now that hospital-based violence prevention programs save lives,” said Dicker. “Violent injury is a public health problem, and it certainly falls within my purview as a trauma surgeon to prevent it.”
Top photo by Cindy Chew and bottom photo by Marco Sanchez, DMM at UCSF.