On this week’s episode, Megan Georges, David Wiley, and Dr. Elizabeth Pino discuss disparities in rehabilitation care access for patients with violent penetrating injuries.

Ms. Georges: Hi everyone. My name is Megan Georges. I am the data and research manager for the Violence Intervention Advocacy Program (VIAP) at Boston Medical Center. It is a hospital-based violence intervention program that’s been around since 2006 and serves individuals treated at Boston Medical Center for assaultive firearm and knife injuries. I am also a member of the Health Alliance for Violence Intervention (HAVI) Research Evaluation Group, which is our national network of hospital-based violence intervention programs. I’ve been working with VIAP since 2022.

Dr. Pino: Hi, I’m Liz Pino. I’m an assistant professor at Boston University School of Medicine, and I previously worked as a research scientist and the data manager for VIAP at Boston Medical Center. I’ve been working and collaborating with VIAP for more than six years now. I’m also a member of the HAVI Research and Evaluation Working Group.

Mr. Wiley: Good morning. My name is David Wiley. I’m a senior program manager at the Boston Public Health Commission’s Community Healing Response Network. I previously worked in the capacity of an advocate at VIAP for 10 years. I also was a member of the HAVI faculty and a national network trainer.

As an advocate at VIAP, I worked with numerous individuals that had debilitating wounds. I’ve witnessed the effects that rehab denials precipitated by bias and stigma toward victims of violence can have on an individual in their recovery. Trying to recover but being denied access to acute rehab can feel demoralizing. As a result, the population we serve becomes even more wary of healthcare providers and practices. We have great healthcare systems in Massachusetts that could help individuals with their injuries, but it’s hard to help them move past the individual wounds that are caused by these denials.

We started to try to explore and address, at the institutional level, some of the core factors behind why people were getting denied, but we didn’t gain good traction. We realized that we needed more evidence to back up our claims and understand what the individuals that we serve were experiencing. We started having discussions with partners at hospitals locally and nationally, and we found that they were experiencing the same issues in different cities and states with the same client population.

Ms. Georges: Thanks, Dave. A lot of this was precipitated by years-long advocacy from our frontline staff, as well as conversations with our partners. We felt this wasn’t a single-institution issue but was happening around the country, as it relates to survivorship for individuals harmed by violence (specifically community violence). We wanted to evaluate if other trauma patients outside of individuals harmed by violence were experiencing differences in denials for inpatient rehabilitation.

We compared motor vehicle crash patients with violence survivors. We examined differences in the reasons for denials and counted the number of denials that individuals experienced during the process of being referred from our hospital at Boston Medical Center to external, inpatient rehabilitation centers. We looked at inpatient rehabilitation facilities as well as skilled nursing facilities and long-term care hospitals.

We first noted how important this is to individuals in their recovery. Rehabilitation is considered a critical juncture in their long-term outcomes. With that being said, about 25% of trauma patients do discharge from hospitals to an inpatient facility—but we know that there are certain types of patients who discharge at lower rates to these facilities, and one of those are violence survivors.

We wanted to take a deeper look based upon what our frontline team was experiencing, what patients were reporting about their experiences, and what we knew from previous studies and data on trauma patients. That’s when we honed in on motor vehicle crash patients versus violence survivors to explore the issue of denial rates.

Dr. Pino: I’ll just add that I think this is such a great example of why partnerships between researchers and frontline violence intervention clinicians is so valuable. As non-clinician researchers, like myself and Megan, we would have no idea that this is such a longstanding issue facing violence survivors if not for the expertise of Dave and other frontline violence intervention staff.

Ms. Georges: I’ll provide a high-level overview of the referral process. For individuals treated for violent injuries in the hospital, when it is determined by the care staff that they need acute rehab or have greater needs than they can access at home, the staff begin referring these individuals to outside institutions for specialized care. The team determines patient needs at the hospital and then send referrals, which include pieces of patient’s charts.

This is why we also honed in on language being used in charts—this process is objective, with individuals’ metrics evaluated for their level of care and needs, but also, there are administrative decisions and conversations occurring in this process. That is why we did a mixed-methods analysis, to explore the language being used in communications in violence survivors’ charts. The referral process continues until a patient is placed in a facility or their needs for post-hospital care change.

Dr. Pino: Our main finding was that violence survivors had 3.5 times greater odds of being denied admission to an inpatient rehabilitation center compared to motor vehicle crash patients. Overall, 58% of our violence survivors had at least one rehabilitation center denial compared to 28% of our motor vehicle crash patients.

Violence survivors were also more likely to be explicitly denied admission due to safety concerns or unspecified reasons. We found no differences in rehabilitation center denials due to things like insurance coverage, bed availability, patient level of care (whether the facility was providing more or less care than the patient needed), or housing concerns. The disparities were due to explicit safety concerns or unspecified reasons. This highlights how rehabilitation center admission processes lack transparency. They lack oversight and seem to be completely subjective based on whom the healthcare practitioner from the rehab facility wants to admit.

Ms. Georges: Another disparity that I want to highlight was that facilities required police contact for nearly 73% of violence survivors during the screening process. Only 3% of motor vehicle crash patients had this requirement. We found this when we were doing chart reviews to determine the reasons for denials and understand violence survivors’ experiences throughout this referral process. We found such a stark difference in that violence survivors were being treated as requiring an extra level of security screening, where facilities felt they needed to know what happened and speak with law enforcement.

This leads to one of our greatest questions from the study: what role does law enforcement have in influencing somebody’s medical needs and the path they take on their continuum of care as they are recovering from a violent injury?

Dr. Pino: It’s also important to note that, for patients suffering from motor vehicle crash injuries, even in instances where law enforcement was involved (ie, if there was impaired driving), the rehabilitation facilities did not need to contact police regarding those types of injuries. It seems like there should be overarching regulation across the board regarding if they need to contact police or not, and it shouldn’t just be targeted towards violence survivors.

Megan, David, and Liz will return next week to share how clinicians can help address these disparities.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.