Strategy 2

Increase Access to Care for At-Risk Populations


Expand access to services for mental health and substance use treatment, as well as for physical health care.



  • The Patient Protection and Affordable Care Act (ACA): The ACA is the comprehensive health care reform law enacted in 2010 that aims to make affordable health insurance and health care services available to more people.

  • Culturally and Linguistically Appropriate Services (CLAS) Standards: CLAS Standards are national standards for health and health care services that are intended to improve the quality of services and help bring about positive health outcomes for diverse populations.

  • Parity laws: These are federal and state laws that affect how insurance plans and policies cover mental health and substance use treatment, requiring that the coverage provided is not more restrictive than coverage for medical or surgical treatment.


In Wisconsin, 40% of people who died by suicide were receiving treatment for mental health or substance use issues at their time of death (See Figure 36.) When such services are covered by a health insurance plan or policy, it is crucial that people are getting the benefits they are entitled to under the law. One such law is the federal Mental Health Parity and Addiction Equity Act (MHPAEA), which requires that the financial requirements (such as co-pays and deductibles) and treatment limitations (such as visit limits) applicable to insurance benefits for mental health or substance use disorders are no more restrictive than the requirements or limitations applied to other medical benefits.

Another federal law, the Patient Protection and Affordable Care Act (ACA), has strengthened MHPAEA’s mandate. The ACA requires insurers who offer coverage through the Marketplace to cover mental health and substance use disorders on an equal basis with coverage for physical health services and not place any annual or lifetime dollar limits on that coverage. Individuals and organizations can continue to work to ensure that access to mental health and substance use treatment for suicidal clients is not limited by insurance benefits that are more restrictive than benefits for other medical issues.


Voices From the Field

"Our American Foundation for Suicide Prevention (AFSP) Field Advocates met with lawmakers in Madison on March 7, 2019, our first AFSP Advocacy Day in Wisconsin, to encourage them to prioritize suicide prevention initiatives for all Wisconsin residents, including efforts to ensure parity in insurance coverage for mental health and substance use conditions. The hope was that by meeting with them we would increase awareness and resources for suicide to save lives in Wisconsin."

– Gena Orlando, Wisconsin Area Director, American Foundation for Suicide Prevention


Lack of insurance is another barrier to accessing physical and mental health care services that, if addressed, could be protective for people at risk of suicide and self-harming behavior. In 2018, results of a state survey showed that the following groups were significantly less likely to be insured:18

  • Hispanics
  • Lower income populations
  • Adults ages 18–44

Suicide prevention efforts targeted toward these populations should address insurance coverage in order to improve access to health care services. Along with services for mental health and substance use, access to physical health care is important. Data shows that in Wisconsin, 25% of people who died by suicide had a physical health problem that was relevant to their death (See Figure 40.) The ACA has provisions to help address gaps in insurance coverage. It created the Marketplace where people who do not have access to employer-based coverage can buy health insurance at affordable rates. It also seeks to expand access to care by increasing the proportion of the population eligible for public insurance (Medicaid). To date, Wisconsin has not opted into Medicaid expansion. However, it is estimated that expansion would enable an estimated 82,000 additional individuals in the state to access affordable health coverage. By covering individuals who currently lack insurance, uncompensated care for providers would decline. In addition, expansion has been linked to positive health outcomes for individuals.

Another way to expand access is by increasing the availability of services that meet the National Standards for Culturally and Linguistically Appropriate Services (CLAS). Some individuals and populations experience barriers to care due to services that are not responsive to their needs based on culture, identity, or language. The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Health care providers and organizations can receive training in the National CLAS Standards to help them incorporate the standards into their practice. There are 15 standards in all, and compliance with the standards can lead to better outcomes for diverse populations, as well as improve the quality of services for everyone.

18. Wisconsin Family Health Survey, 2018: Key Findings. Wisconsin Department of Health Services, September 2019.

2A: Expand access to services

Opportunities for Action Resources
Support efforts to ensure that parity requirements for insurance are being met. Wisconsin Office of the Commissioner of Insurance, Consumer Health Information
American Foundation for Suicide Prevention
Mental Health America
Assist with outreach strategies to ensure that all eligible people are enrolled in Medicaid or private insurance through the Marketplace. Covering Wisconsin
Federal Health Insurance Marketplace
Wisconsin Office of the Commissioner of Insurance
Promote and advance the adoption of the National Culturally and Linguistically Appropriate Services (CLAS) Standards. Wisconsin Department of Health Services’ National CLAS
Standards webpage
Federal HHS Think Cultural Health
Build on efforts to integrate mental health and substance use disorder treatment with primary care systems to reduce stigma around accessing services and improve integrated care. Center of Excellence for Integrated Health Solutions
Health Resources and Services Administration




Support innovative ways to expand access to care, including technologies and peer-led or other non-clinical support services.



  • Clinical services: These are services provided by a licensed clinician (e.g., a doctor, psychologist, or counselor) to treat individuals who have mental health or substance use disorder diagnoses. Such services are often provided in a clinical setting, such as a hospital or medical office.

  • Non-clinical support services: These are services provided by a variety of professionals and laypeople in diverse settings to assist individuals with mental health or substance use issues, regardless of whether they have a diagnosis.

  • App: An “app” or “smartphone app” is a mobile application, which is a type of software designed to run on a mobile device, such as a smartphone or tablet computer.

  • Telehealth: Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health care facilities. Telehealth, which requires access only to telecommunications, is the most basic element of “eHealth,” which uses a wider range of information and communication technologies.


A person’s care for mental health or substance use conditions, as well as suicidal thoughts and behaviors, can sometimes be met in settings other than clinical settings. With advancements in technology, individuals have more options for accessing telehealth, as well as online or mobile resources. In addition, access to non-clinical support services has been increasing and could be expanded further. These services are often provided by people who have experienced life struggles similar to those being experienced by individuals seeking services.


Voices From the Field

"The Medical College of Wisconsin’s Department of Psychiatry has developed a concept for an innovative consult program which could deliver specialized psychiatry consultation services to primary care providers across the state by building onto the infrastructure of the state supported Child Psychiatry Consultation Program, including general psychiatry, geriatric psychiatry, veteran psychiatry, addiction psychiatry, perinatal psychiatry, and non-opiate pain management expertise. No other state has something like this population health focused program. The State of Wisconsin funded the development of a business plan for this program. "

– Jon A. Lehrmann, MD, Professor and Chairman, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin


Smartphone apps

Apps are free or inexpensive tools that can supplement clinical services or can be used by an individual to manage their condition on their own. They work by collecting data from users, such as tracking symptoms, and then providing feedback or even recommendations to their users. The number of apps is increasing rapidly, and there are apps designed for a wide range of mental health conditions. Texting or app-based messaging crisis lines can also meet a need for individuals who prefer to type or text rather than speak on the phone with someone, or for individuals who are deaf or hard of hearing. While apps are seen as a promising and low-cost way to address gaps in access to mental health treatment, their effectiveness is still being studied. Caution is advised when considering use of these apps, as some may make claims not supported by research and may also sell the user data they collect.

Clinical provider telephone consultation

The Wisconsin Child Psychiatry Consultation Program (CPCP) provides consultation, education, and referral support to enrolled primary care providers caring for children and adolescents with behavioral health challenges. The Wisconsin CPCP is similar to other national models designed to address child and adolescent psychiatry shortages. Since its establishment in 2014, CPCP has grown rapidly and successfully, with increased resources, as a model to expand access to behavioral health expertise to primary care providers across the state. There is potential for this type of consultation service to be expanded to serve adults in Wisconsin as well.

Peer support and certified peer specialists

In this context, a peer is someone who shares the experience of living with a mental health or substance use issue, which may include having experienced suicidal thoughts or behaviors. As peer support, they develop trust with a person experiencing similar challenges by providing a nonjudgmental and safe space to explore issues, give and receive encouragement, share knowledge, and support a person’s path to recovery. Peer support can increase access to needed help by providing a form of care within a relationship of equals that is non-clinical, strengths-based, and self-directed. For some people, this is the form of care that works best for them. Peer support can also provide benefits as part of mental health and substance use treatment services. That type of peer support may be provided by a certified peer specialist, a title for an individual who has had formal training and continuing education in the peer specialist model of mental health and substance use disorder support. Certified peer specialists are increasingly being used in crisis intervention services programs (also called emergency mental health services programs) to add the wisdom of lived experience to the resolution of crisis situations.

Peer groups

Alternatives to Suicide is one example of a peer-led group. Alternatives to Suicide is specifically for people living with suicidal thoughts. People attending these groups are encouraged to talk openly about their current issues, share ideas for coping, and discuss challenges and successes.

Peer-run respites

A peer-run respite is a place where adults with mental health and substance use concerns who are experiencing increased stress or symptoms can seek respite by being a guest in a home-like, peer-supported environment. Peer-run respites are managed by people who have also lived through emotional, psychological, and life challenges. Staff are on-site 24/7 and are trained in how to help guests improve their quality of life. Guests share their recovery goals, which may include connecting with community resources, engaging in wellness activities like art or exercise, or finding a safe space for healing. There is not a doctor on staff, and there is no medication management or therapy provided, though staff can assist guests in connecting with mental health or substance use services in the community. Prospective guests contact the peer-run respite to schedule overnight stays, which typically last less than one week.

This model has been successful in Wisconsin with hundreds of Wisconsin residents having received support and direct referrals to community resources. These services are provided without cost to guests and are designed to aid in the guest’s recovery, avert crises, and avoid psychiatric hospitalizations.

Telehealth model

One way to assess availability of behavioral health services is to measure the ratio of the population (number of residents) to the number of mental health and substance use providers in a given county. The following map depicts those ratios, which vary widely across the state. A lower ratio, as depicted by the lighter blue shades, indicates a higher number (greater availability) of behavioral health care providers. Many counties across the state have high ratios (darker red) that suggest significantly limited availability of behavioral health care providers.



Figure 47. Data presented here includes both mental health and substance use providers in the National Provider Identifier database. This shows that counties in Wisconsin have varying mental health and substance use provider capacity. Notably, rural areas often have high ratios of population to provider, which can signify shortages and affect access. This ratio would be the number of people living in the county that would be under the care of one provider, if hypothetically every person living in the county was seeking services and each provider had an equal number of clients.

Project ECHO® (Extension for Community Healthcare Outcomes) is a nationally recognized telehealth model to extend specialist care through primary care systems and providers in rural and underserved areas. Developed in New Mexico beginning in 2003, Project ECHO® has now been adopted in over 46 states. This includes Wisconsin at the University of Wisconsin’s (UW’s) Department of Surgery and Department of Family Medicine and Community Health, as well as the Wisconsin Department of Health Services. The UW Project ECHO® clinics provide expert review and guidance on pediatric emergency care and surgical indications, as well as treatment and response to substance use disorders or addictions.

2B: Support innovative ways to expand access to behavioral health services

Opportunities for Action Resources
Encourage the safe use of smartphone apps and the evaluation of their effectiveness. Crisis Text Line Referrals
Mental Health Apps (APA)
Support the expansion of telehealth. Project ECHO® Telehealth Model
Support the expansion of clinical provider telephone consult programs. The Wisconsin Child Psychiatry Consultation Program (CPCP)
Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine
Promote the implementation
and expansion of peer-led services
and programs.
Peer-Run Respites
Alternatives to Suicide Peer-to-Peer Groups
NAMI Wisconsin Peer Support Groups
NAMI Wisconsin Peer Leadership Council
NAMI Connection
Wisconsin Peer Specialists




Increase the public’s knowledge of risk factors for suicide, recognition of warning signs in individuals, and preparedness to support and respond to those individuals.



  • Suicide prevention training: This is often referred to as “gatekeeper training” when it is provided to the general public. The aim of this type of training is to prepare people to recognize someone at risk of suicide and respond by referring them to appropriate resources.

  • Postvention: This is an organized response in the aftermath of a suicide to accomplish one or more of the following:
    • Facilitate the healing of individuals from the grief and distress of suicide loss.
    • Mitigate other negative effects of exposure to suicide.
    • Prevent suicide among people who are at high risk after exposure to suicide.

  • Suicide contagion: This describes an increase in suicide and suicidal behaviors due to exposure to such behaviors within one’s family, peer group, or through media reports of suicide or suicide attempts.

  • Public messaging: In this context, public messaging is the dissemination of information and messages about suicide in websites, social media, news articles, educational materials, billboards, and other print and digital communications. It is important that this information be conveyed in ways that support suicide prevention rather than increase risk.


There are a number of ways to increase the public’s knowledge of risk factors and prepare people to respond to individuals who may be in crisis. The Wisconsin Violent Death Reporting System provides narrative information from coroners and medical examiners, as well as law enforcement, that can be used to learn about the circumstances present in the life of individuals who died by suicide. This information can then be used to guide prevention. Figure 48 displays suicide-related themes that were qualitatively extracted from narratives, broken down by age group. The age groups used represent pre-high school age (10 to 13), high school age (14 to 17), young adult (18 to 24), working age adult (25 to 44), middle years (45 to 64), and retirement age (65 and older). The similarities and differences displayed in this table indicate that, while there are some shared contextual factors present across age groups, different age groups experience different life stressors prior to a death by suicide.


 Figure 48. Top 5 suicide-related themes by age group

Themes 10–13 14–17 18–24 25–44 45–64 65+
1. Recent argument with parent Recent argument with parent Alcohol use Alcohol use Alcohol use Physical health problems
2. Bullying victim Bullying victim Legal issues Financial strain Physical health problems Chronic pain
3. Loss of privileges/items Self-harm Substance abuse Argument with partner Financial strain Anxiety
4. History of self-harm Alcohol use Argument with partner Anxiety Chronic pain Cancer diagnosis
5. Recent suspension from school Anxiety Relationship problems Physical health problems History of alcohol misuse History of alcohol misuse


Note: The age groupings used in this analysis differ from age groupings used in other parts of this report. The age groupings here are based on the most common themes.

Source: Wisconsin Violent Death Reporting System, 2012–2016.

Suicide prevention training

There are many tools available for training people to recognize the warning signs of someone who might be in crisis and prepare them to intervene. The Centers for Disease Control and Prevention (CDC) provides a technical package that includes best practices on identifying and supporting people at risk.19 For example, QPR (Question, Persuade, and Refer) is a short educational program that provides simple instructions for intervening with individuals considering suicide in the same way that CPR provides instructions for assisting people who have a physical need. Though QPR was developed for a general community audience, it can be adapted for use by specific groups of professionals or volunteers who interact with people at risk of suicide.

It is critical that the public be aware of appropriate referrals when a person is at risk. Crisis intervention approaches provide support and referral services, typically by connecting a person in crisis to trained volunteers or professional staff via telephone hotline, online chat, text messaging, or in-person. Wisconsin crisis intervention services programs (also called emergency mental health services programs) provide 24/7 phone services to most counties. These programs also provide walk-in and mobile services during significant portions of the week.

19. CDC Preventing Suicide: A Technical Package of Policy, Program and Practices.

Culturally relevant interventions

While suicidal thoughts and behaviors can occur in all populations, there are certain populations at disproportionate risk of suicide, such as: individuals with lower socio-economic status; individuals living with a mental health issue; suicide attempt survivors; veterans and active duty military personnel; individuals who are institutionalized, have been victims of violence, or are experiencing homelessness; lesbian, gay, bisexual, or transgender individuals; and members of certain racial and ethnic groups. Prevention approaches are not “one-size-fits-all.” It is important to further explore and develop culturally relevant resources for groups at disproportionate risk of suicide and offer opportunities for these interventions to take place where groups at risk spend most of their time.

Engaging individuals in non-traditional sectors

Non-traditional sectors, meaning sectors where suicide prevention efforts do not typically occur, that could be engaged in creative efforts include: government (local, state, and federal); social services; business; labor; justice; housing; media; and organizations that comprise the civil society sector, such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Countless opportunities exist to educate the public about risk factors for suicide and increase the ability to respond in a supportive, nonjudgmental way.


Voices From the Field

"Increasing public awareness of suicide warning signs, how to identify individuals who are struggling, those in crisis, and knowing how to reach out to them, is imperative to reducing the likelihood of the occurrence of suicide. The American Foundation for Suicide Prevention is dedicated to educating communities by offering lifesaving education programs like Talk Saves Lives, More than Sad, and It’s Real: College Students and Mental Health, at no cost to participants."

– Gena Orlando, Wisconsin Area Director, American Foundation for Suicide Prevention


Postvention approaches

Research has established that family members of people who have died by suicide are at increased risk of suicide themselves.20 Postvention strategies are positive approaches that can be implemented after a suicide death in order to support individuals bereaved by suicide loss. They are activities designed to promote healing and reduce suicide risk among loss survivors. Strategies can include debriefing sessions; counseling; bereavement support groups; and outreach to the affected community through schools, workplaces, and places of worship. In order to be prepared for postvention needs after a suicide death, training on postvention must be provided in advance to first responders, school personnel, coroners and medical examiners, funeral directors, and others who have contact with recently bereaved individuals. Postvention is future prevention. 

Safe messaging about suicide

The way that suicide is portrayed in the media, on social media, and in other public forums matters. The media plays a large role in preventing suicide contagion. It is important that media outlets and community organizations use safety-focused guidelines when reporting on suicide events and presenting data. Communications about suicide should be designed to encourage help-seeking, focus on positive prevention efforts, promote hope and resiliency, and include vetted helping resources such as county crisis lines, the National Suicide Prevention Lifeline, and the HOPELINE Crisis Text Line. (See Additional Resources in Appendix 1.)


"People with mental health challenges sharing their recovery experiences in a targeted, local, credible, and continuous way is the current, primary, evidence-based practice to reduce stigma."

– WISE (the Wisconsin Initiative for Stigma Elimination)


Reducing stigma

According to WISE (the Wisconsin Initiative for Stigma Elimination):

The stigma associated with mental illnesses prevents treatment and impedes recovery. It is fundamental to discrimination in housing, employment, healthcare and insurance reimbursement. Stigma impacts productivity in the workforce and community health. Research on addressing discrimination and stigma has shown that individuals’ attitudes improve when they have direct contact with people with mental illnesses, when they can get to know people beyond labels and myths (contact strategies). Research also demonstrates that some efforts to reduce stigma such as protesting and education about illnesses, while well intentioned, in some cases have actually increased the negative attitudes and behaviors of stigma. If one of the goals of a presentation is to reduce stigma, contact with a person living in recovery has been shown to be the most effective both immediately after the presentation and in follow-up evaluations.

Targeted media strategies and initiatives within specific sectors, such as workplaces, health systems, and schools, can work to eliminate stigma around mental health and suicide by engaging people with lived experience (those who have survived an attempt or lived with suicidal ideation) to reduce stigma through intentional contact strategies, such as those supported by WISE.


Meeting people where they are

  • Several coalitions and local health departments in Wisconsin work with bartenders to disseminate suicide prevention messaging in local bars and restaurants.
  • A faith-based mental health group in Milwaukee hosts suicide prevention events at churches and community centers.
  • A Wisconsin construction company offers QPR trainings at their headquarters.
  • Gun shop owners share their own stories of suicide loss to start the conversation about prevention with their customers.
  • A farmer in rural Wisconsin speaks at mental health awareness events and leads a group to bring other farmers together to talk about daily stress and other issues.

This list is not comprehensive. There are abundant opportunities to reach at-risk individuals in the community, including at: hair salons and barber shops; public transportation; banks and credit unions; domestic violence and homeless shelters; perinatal programs; family courts; re-entry programs for individuals following incarceration; and substance use treatment programs.


20. Pittman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. Lancet Psychiatry, 1, 86–94. doi:

2C: Increase the public’s knowledge of risk factors and preparedness to respond

Opportunities for Action Resources
Train communities to identify suicide risk and effectively intervene and support individuals in crisis. QPR Institute
Mental Health First Aid
Applied Suicide Intervention Skills Training-ASIST
Talk Saves Lives
Wisconsin County Crisis Lines
National Suicide Prevention Lifeline
1-800-273-8255 (TALK)
HOPELINE Crisis Text Line
Text “HOPELINE” to 741741
Educate communities on the
prevalence of suicide and how to provide appropriate support and resources to those experiencing suicidal thoughts
or behaviors.
American Foundation for Suicide Prevention (AFSP) Education Programs
Prevent Suicide Wisconsin Annual Conference
Prevent Suicide Wisconsin Suicide Prevention Month
Suicide Awareness Voices of Education-SAVE
Department of Public Instruction (DPI) Training
Sowing Seeds of Hope (Farmers, Rural Health)
Suicide Prevention Resource Center (SPRC) About Suicide
WISE (Wisconsin Initiative for Stigma Elimination)
Provide support and resources to communities dealing with suicide loss. Responding to Grief, Trauma and Loss after a Suicide—National Guidelines
After a Suicide: A Toolkit for Schools
A Manager’s Guide to Suicide Postvention in the Workplace: Ten Action Steps for Dealing with the Aftermath of Suicide
Postvention: A Guide for Response to Suicide on College Campuses
AFSP I’ve Lost Someone
Prevent Suicide Wisconsin Suicide Loss Support
Share safe and effective messages about suicide and suicide prevention in public communication efforts. Action Alliance Framework for Successful Messaging
Action Alliance Media Messaging Task Force
Recommendations for Reporting on Suicide
Prevent Suicide Wisconsin Prevention Messaging
American Association of Suicidology (AAS) Media Reporting on Suicide