Informed by economic evaluation and analysis frameworks [20] for nonprofit [19] and public [21] interventions, this case study and customizable workbook breaks down the costs of an HVIP. It applies Schnippel and colleagues’ 2023 ingredients-based, bottom-up methodology [22]. Key resources and unit costs were determined by analyzing five diverse HVIP program budgets, interviewing staff, and cross-validating key resources against the country’s leading HVIP training and technical assistance (TTA) provider, the Health Alliance for Violence Intervention’s Standards and Indicators report [10]. All costs are from the perspective of the organization implementing the HVIP. While discussed, results do not reflect a societal perspective, as costs to the patients and external wraparound service providers are not included. Some HVIPs may have volunteers or receive in-kind donations of supplies from the community, but these voluntary contributions are not assumed in this analysis.
Cost assumptions are separated by budget category (i.e., staff, operations, crisis support, transportation, and indirect costs). They reflect three years of implementation and funding to distinguish between upfront and sustained costs and comply with common funding proposal requirements. Beginning with projections for 2024, an annual inflation factor of 2.6% was applied [23]. Users can view and edit all units, costs, and formulas featured in this analysis via the customizable costing workbook, including key parameters such as salaries, number of anticipated participants, and level of crisis support provided to reflect local needs and priorities.
Organizational Structure Assumptions
HVIPs typically bring together a hospital, a community-based organization (CBO), and wraparound service providers to support violent injury survivors during the particularly vulnerable period following hospitalization (see Fig. 1). The hospital is often one with a Level I Trauma Center or ED treating over 100 patients with violent injuries annually [24]. The CBO is typically a nonprofit, as is assumed here, but they can also be housed within a local university or city government office of violence prevention. HVIPs can be led by either a CBO (i.e., hospital-linked) or a hospital (i.e., hospital-based). Benefits of hospital-linked HVIPs include well-established community networks and lower indirect costs, and hospital-based HVIP benefits include easier data access and regional scalability [10].
Wraparound service providers represent another essential component of HVIP functioning, offering key resources like job training and placement; substance use counseling; tutoring and GED preparation; legal advocacy; tattoo removal; rental or housing assistance; victim services, and more. As is often the case, this costing analysis assumes that these services operate independently via separate funding streams. While this means that they are not required to accept all HVIP referrals, strong programmatic relationships can help to strengthen these outcomes. In some instances, an HVIP may decide that a particular service is essential enough to merit a deeper level of engagement and inclusion in their budget.
Target participants are often youth and young adult survivors of nonfatal violence, excluding domestic violence and self-harm, and explicitly including those with prior justice system contact and/or physical disabilities. This case study assumes that a midsize city’s hospital-linked HVIP serves 100 participants annually for an average of nine months each.
[Figure 1 about here]
Costing Assumptions
This analysis assumes that the CBO employs eight permanent full-time-equivalent (FTEs) positions, including a director, an intervention supervisor, a clinical supervisor, an administrator, and four VPPs. Hospitals also contribute a small portion of business and medical staff time, often (and in this case study) in-kind, toward activities like program leadership, participant identification, and training. All CBO staff members, but especially the VPPs, should be culturally competent, credible messengers, often with shared lived experiences. While not assumed in this case study, some programs may require VPPs to be licensed social workers, in which case such programs should budget for higher salaries accordingly. Across the country and in this case study, VPPs manage an average caseload of 14 to 17 participants at any given time [25]. Drastic variations from this—or extending full services to survivors’ family members as well—may warrant the hiring of additional VPPs. For more on each staff member’s responsibilities, which in turn inform their salaries [10, 25], see Table 1.
[Table 1 about here]
Salaries were based on average rates for similar, local public-sector employees, available via OpenPayrolls.com. This case study assumes a starting salary of $60,000 for VPPs specifically, modeled after several cities’ and programs’ recent commitments to ensuring livable wages and benefits for violence intervention workers [26]. Total cost to employers (TCE) incorporates mandatory and optional contributions. The mandatory portion reflects an additional 13.3% uptick for federal payroll taxes like Medicare, Social Security, and unemployment. State requirements can be added using the customizable workbook. The TCE also includes a 25% markup for competitive benefits provided to salaried employees, such as professional development and accreditations, cell phone stipends, and employer contributions to mental/health, vision, dental, disability, retirement, and life insurance. Annual salary raises reflect inflation plus a 2.4% performance increase.
Assumed operations costs include primarily equipment needs, like laptops or tablets, desks and chairs, printing materials, kitchen supplies, and uniforms. Much of this equipment should last multiple years, but may be damaged, lost, or broken. This case study assumes that 20% of the applicable equipment will require annual replacement and that costs for these devices will rise with inflation. Annual case management and evaluation software licenses are also included, along with year-one TTA fees, to support initial program development, training, and implementation. As is often the case, this analysis assumes that the HVIP is physically located within a hospital at no cost to the program for these expenses [25].
Regarding crisis support, this case study also assumes that, in an average year, 80% of participants will require food vouchers and hygiene kits, and 30% will require two nights of temporary housing, emergency clothing, and other resources (licenses, course registrations, etc.). This budget category varies the most across programs, in light of two conflicting challenges: difficulty with fundraising for discretionary dollars [27] and many violent injury survivors’ need for significant immediate cash resources [28].
Transportation cost assumptions include public transportation stipends for participants and mileage reimbursement for staff. Each participant has their trip home from the hospital, along with four roundtrips to their first wraparound service appointments included in the program budget. VPP mileage to attend these initial appointments is included as well, along with staff mileage to make at least one home visit per participant. Average miles per trip assumes typical distances within a midsize city.
Lastly, in accordance with typical funding guidelines, a 15% indirect rate for a hospital-linked HVIP is assumed for all other personnel, administrative, and back-end costs not accounted for in the aforementioned line items. For hospital-based HVIPs, a higher indirect rate of 35% is common.