This qualitative study revealed key features of effective implementation of HVIPs as well as challenges to the collaborative care model used in some evaluated programs. The RE-AIM QuEST framework provided an evidence-based structure for our analysis [19, 22,23,24].

The first domain of the framework addressed patient engagement. Our results indicated that CHWs felt well prepared to engage patients because of their lived experience within their community. While our data is limited by our sample size of CHWs, these results are supported by prior research noting the importance of lived experience [17]. Knowing their communities and the way violence exists within them facilitated efforts to engage and support victims of violence with empathy. Additionally, while lived experience is important, it by itself is insufficient to make effective CHWs, as training, cultural competence, and communication skills, among other attributes, are equally important [25].

While CHWs were well equipped to engage victims of violence, LAHVIP was only able to enroll a fraction of the thousands of victims of violence admitted to the three participating major hospitals serving a vast urban area. The lack of stable housing and contact information within this population presented a significant challenge to enrollment. These issues are not unique to these programs. Another urban program aiming to enroll individuals with non-fatal assaultive firearm injuries succeeded in engaging only 12% of eligible individuals [20]. Proposed initiatives to support unhoused persons may serve to reduce violence and facilitate future efforts to address socio-emotional challenges of victims of violence [20, 26, 27].

Another barrier to enrollment was lack of familiarity with the program among hospital staff. The HVIP model relies on rapid referral by hospital staff. This method of identification was compromised by poor awareness and engagement among hospital staff particularly within the hospital-linked programs. While efforts were made to educate staff about HVIP, this was not enough to improve incentives for staff to engage. More top-down support from the hospitals is likely needed to encourage hospital staff to participate.

A third domain of the framework was consistency of delivering the intervention. CHWs and other stakeholders emphasized their commitment to the HVIP model and its mission, which contributed to consistency. To accomplish the goal of assisting patients, CHWs emphasized their personal efforts. For example, they scheduled appointments with service providers in addition to physically accompanying patients to appointments to ensure that the providers’ plans were carried out. CHWs acknowledged that at times they helped patients using their private money or resources. This level of commitment is helpful but demonstrates gaps in other aspects of program implementation such as funding. Furthermore, the use of personal resources could lead to staff burnout.

Consistent delivery of LAHVIP was also facilitated by program champions such as physicians, nurses, or other staff at participating hospitals. Champions identified eligible patients after admission for referral to CBOs and advertised the program to colleagues. A recent review reinforced the key role of clinical champions in the care and support of victims of domestic violence [28]. Yet the champion role is often informal and uncompensated. As a result, their commitment is much less certain and they are more predisposed to burnout.

Process challenges, for example, lack of CHW access to the hospital’s electronic medical record, were another barrier to consistency for the hospital-linked programs in particular. The HVIP model entails engaging patients admitted day or night, as patients often have limited hospital stays. Each hospital would ideally have one CHW onsite at all times, but this was not always achieved. For example, at one site there was a period when only one CHW had access to patients, as other CHWs were involved in a prolonged and unclear credentialing process.

This challenge was made worse by frequent staff turnover. Turnover of CBO staff and CHWs can lead to the loss of personnel with the relationships, skills, and knowledge to effectively navigate the complexities of the local resource environment. New personnel requires substantial training using a standardized curriculum as well as interpersonal skills training. Therefore, programs often lose well-trained staff during times of funding cuts, only to spend considerable resources training new staff when funding returns. Because of the tenuous nature of funding, one group has suggested performing a risk stratification for the likelihood of future violence to identify those in most need of HVIP services [29]. Such an initiative could ensure a more intensive and consistent delivery of services but may miss individuals who could benefit greatly from the program.

Finally, RE-AIM QuEST addressed if the intervention ultimately achieved its goals: reduction in violent reinjury and the provision of services or resources. Both hospital and CBO interviewees noted that enrolled patients received needed services and support. Moreover, the CHWs served as positive role models who reinforced the value of programs. For example, CHWs helped individuals stay away from illicit or gang-related activity.

In this qualitative study, patients in the program were not interviewed, and therefore we did not obtain information on whether enrolled individuals were able to find housing or other social support. We were also unable to assess how effective patients felt the programs were in preventing future violence. However, the ability of HVIPs to reduce the severity and frequency of violent activity is evidenced by clinical trials which demonstrated that HVIP participants have significantly less prison time than controls [12]. A systematic review of HVIP-like programs for victims of violence in the emergency department also reported statistically significant improvements in multiple measures of subsequent violence [30]. Still, the ability of programs may be limited in terms of their effectiveness to address housing and mental health [16]. It is essential to perform future studies that more comprehensively evaluate quantitative outcomes such as these measures of violence for the LAHVIP.

The success of the HVIP model relies on adequate funding for this program. Everytown for Gun Safety estimated that in a mid-sized city, funding for an HVIP would require $10,800 per participant; in a large city with thousands of victims of violence this would cost millions of dollars [31]. However, the funding is not only for the HVIP itself. Stakeholders often discussed substantial waitlists and delays between applying for services or resources and patients receiving them. Many services were at county or municipal levels and not under control of the HVIP program staff, which served as a source of frustration. These delays led patients to drop out of the program.

Hospital-based violence intervention programs require the close collaboration of hospitals and community service providers to function. As prior qualitative investigations have noted, the quality of this collaboration is key to facilitating the linkage of needed resources, services, and support to patients [21].

This qualitative study has several limitations. First, LAHVIP was implemented in one of the nation’s largest cities and our findings may have limited external validity in rural areas due to the program’s urban setting. Nevertheless, to our knowledge, this is the first qualitative study of implementing an HVIP across multiple hospitals and CBO organizations. Second, this analysis did not examine the experiences of patients served by this program. Third, our findings may be influenced by interviewer positionality, participant awareness of our research aims, and relationships between study team members and participants. Lastly, this study is limited by its qualitative methodology and its usefulness is primarily limited to hypothesis generation. We hope, however, it will help guide other systems in developing or maintaining HVIPs.

Implementation barriers in LAHVIP persist largely due to a lack of integration between hospitals and community-based organizations (CBOs). To improve coordination, several changes could be made. First, shared funding responsibility between hospitals and CBOs would help alleviate financial pressures on programs and incentivize better collaboration. This would also address the current instability in CBO staffing, which is heavily reliant on short-term grants. Second, coordinated information campaigns for hospital staff would improve cooperation between case managers and providers. Standardizing workflows and integrating technology—such as shared patient data systems—would streamline patient enrollment and ensure more consistent care. To further enhance integration, HVIP workers should be co-located within the hospital teams, making them a core part of the healthcare infrastructure, similar to other community health workers. This co-location model is a best practice which has already been implemented in some programs [21]. Lastly, patient enrollment could be enhanced by using novel communication strategies such as social media to stay in contact with individuals without access to phones. These changes would not only improve program efficiency but also foster hospital buy-in, ensuring that HVIPs are seen as vital members of the healthcare system, ultimately improving patient outcomes.