We are working to implement a first-of-its-kind comprehensive bullet injury recovery program for people at Kaiser Permanente Washington and Colorado who experience bullet related injuries. We aim to holistically address medical (e.g., wound care, pain), psychological (e.g., trauma recovery), and social needs (e.g., social reintegration, addressing determinants of health), and reduce barriers to accessing and maintaining care. We are currently in the design phase and plan to pilot BIRCH in 2026.

We have been working with folks around the country to develop BIRCH. Activities include:

• Systematic literature review for evidence-based recovery best practices
• Key informant interviews with national program leads and KP patient members
• Designing care packages called “BIRCH boxes,” in collaboration with our colleagues at the Bullet-Related Injury Clinic in St. Louis (national leaders of bullet-injury recovery) who developed the “BRIC box" (our model for BIRCH) to support injury recovery
• Working with KP clinicians and leaders to understand KP workflows and needs

Those impacted by bullet injury need more support

Each year, approximately 120K people in the US survive bullet-related injuries, accounting for over 1.1 million healthy life-years lost before age 65.^(1,2) Most are discharged from acute care with minimal structured follow-up despite substantial ongoing medical, behavioral health, and social needs.^(3-5) The downstream impact is significant:

• Survivors of firearm injuries require prolonged medical, surgical, and rehabilitative care, with marked increases in pain, psychiatric, and substance use disorders after injury.⁽⁶⁾
• Average index firearm injury hospitalizations exceed $95,000, and additional use in the year after discharge can roughly double these costs.^(7-9)
• Nonfatal firearm injury survivors face high risk of repeat violence, with substantial proportions sustaining another violent injury or arrest within a year.⁽¹⁰⁾
• More than half of survivors screen positive for PTSD or other serious mental health symptoms months after injury, with ongoing functional impairment.^(3,11)
• Black and brown communities in low-income, high-need areas experience far higher rates of nonfatal firearm injury and worse access to high-quality recovery care.^(12-14)

KP already has much of the core infrastructure to respond: medical centers, clinics, community health workers, and social health screening workflows. We are working to more intentionally and holistically deploy resources toward this high-risk population.

Learn more about resources for clinicians coming soon!
Learn more about resources for community members coming soon!

References 

1. Kim R, Wagner, E. D., Nestadt, P. S., Somayaji, N., Horwitz, J., & Crifasi, C. K. Gun Violence in the United States 2023: Examining the Gun Suicide Epidemic. 2025. https://publichealth.jhu.edu/sites/default/files/2025-06/2023-cgvs-gun-violence-in-the-united-states.pdf 
2.  Center for Disease Control and Prevention NCfIPaC. Web-based Injury Statistics Query and Reporting System (WISQARS) 2024. https://wisqars.cdc.gov/ 
3. Strong BL, Lauerman MH, Scalea TM. Sequelae and Care After Firearm Injury. JAMA. 2025;334(8):726-727. doi:10.1001/jama.2025.10498
4. Brandolino A, deRoon-Cassini TA, Biesboer EA, et al. Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic. Trauma Surg Acute Care Open. 2024;9(1):e001199. doi:10.1136/tsaco-2023-001199
5. Strong BL, Lauerman MH, Scalea TM. Sequelae and Care After Firearm Injury. JAMA. Jul 23 2025;doi:10.1001/jama.2025.10498
6. Zirui Song JRZ, Mia Giuriato, Erica Paulos, and Katherine A. Koh, . Changes in Health Care Spending, Use, and Clinical Outcomes After Nonfatal Firearm Injuries Among Survivors and Family Members. Annals of Internal Medicine. 2022;175(6):795-803. doi:10.7326/m21-2812 %m 35377713
7. Du J, Andrews A, Gastineau K, et al. Pediatric Nonfatal Firearm Injury Health Care Utilization. Pediatrics. 2025;156(1)doi:10.1542/peds.2024-070424
8. Silver JH, Ramos TA, Stamm MA, Gladden PB, Martin MP, Mulcahey MK. Examining the Healthcare and Economic Burden of Gun Violence in a Major US Metropolitan City. J Am Acad Orthop Surg Glob Res Rev. Aug 1 2023;7(8)doi:10.5435/JAAOSGlobal-D-22-00158 
9. Peek-Asa C, Butcher B, Cavanaugh JE. Cost of hospitalization for firearm injuries by firearm type, intent, and payer in the United States. Inj Epidemiol. Dec 2017;4(1):20. doi:10.1186/s40621-017-0120-0
10 Morrison CN, Jacoby SF, Dong B, et al. Incidence of and Factors Associated With Recurrent Firearm Injury Among Victims of Violent Injury in St Louis, Missouri. JAMA Netw Open. 2023;6(8):e2329854. doi:10.1001/jamanetworkopen.2023.29854
11. Biesboer EA, Brandolino A, Tomas CW, et al. Firearm injury survivors report extreme high risk for poor physical and mental health outcomes early after hospital discharge necessitating multidisciplinary care. Trauma Surg Acute Care Open. 2025;10(1):e001336. doi:10.1136/tsaco-2023-001336
12. Kaufman EJ, Song J, Xiong R, Seamon MJ, Delgado MK. Fatal and Nonfatal Firearm Injury Rates by Race and Ethnicity in the United States, 2019 to 2020. Ann Intern Med. Sep 2024;177(9):1157-1169. doi:10.7326/M23-2251
13. Boeck MA, Strong B, Campbell A. Disparities in Firearm Injury: Consequences of Structural Violence. Current Trauma Reports. 2020/03/01 2020;6(1):10-22. doi:10.1007/s40719-020-00188-5 
14. Schnippel K, Burd-Sharps S, Miller TR, Lawrence BA, Swedler DI. Nonfatal Firearm Injuries by Intent in the United States: 2016-2018 Hospital Discharge Records from the Healthcare Cost and Utilization Project. West J Emerg Med. May 21 2021;22(3):462-470. doi:10.5811/westjem.2021.3.51925