Implement Best Practices for Prevention in Health Care Systems

3A

Promote a systematic “Zero Suicide” approach, rooted in the understanding that suicide is preventable in people receiving treatment services.

 

Definitions:

  • Zero Suicide: The Zero Suicide framework is a systemwide, organizational commitment to safer suicide care in health and behavioral health care systems.

  • Suicide Prevention Resource Center (SPRC): SPRC is the federally supported national resource center devoted to advancing suicide prevention infrastructure and capacity building through consultation, training, and the provision of information, resources, and tools in support of suicide prevention efforts.

 

The Zero Suicide Framework

The Zero Suicide framework is grounded in the most current, systematic, and evidence-based research in suicide prevention. Core concepts include:

  • Zero suicide deaths— If zero isn’t the right number, what is? In trying to determine an “acceptable” number of suicide deaths, you reach the conclusion that zero deaths is a hopeful and aspirational goal.

  • Paradigm shift— A fundamental shift away from accepting suicide as an occasional consequence of mental illness to an understanding that suicide is preventable.

  • Systems approach— A focus on systemwide quality improvement rather than blame when suicide attempts and deaths do occur.

  • Quality improvement— An emphasis on improving systems and developing systemwide policies and procedures instead of relying solely on the efforts of individuals.

  • Health systems commitment— Zero Suicide provides an aspirational challenge and practical framework for systemwide transformation in health care systems toward safer suicide care.

 

Voices From the Field

"Involving people with lived experience is important because they may have a different outlook because they have first-hand experience of what it is like to struggle through mental illness or loss from suicide. They can speak the same language as someone that has been through similar struggles. "

– Patty Slatter, NAMI Rock County, Person with Lived Experience

 

With the knowledge that suicide deaths can be prevented for individuals receiving care in health and behavioral health systems, suicide prevention is increasingly being seen as a core responsibility of health care. This culture shift is the foundation of the continuous quality improvement model called Zero Suicide. The Zero Suicide framework is based on a systematic approach to quality improvement; it does not rely on the heroic efforts of individual clinicians but rather the conscientious and consistent use of specific tools and strategies throughout organizations. Just as health systems have been able to initiate systematic practices and policies to eliminate medical errors and falls, the Zero Suicide framework can reduce and has reduced suicide by individuals receiving care, with the aspirational goal of reducing the number of suicides to zero.

Toward Zero Suicide in Wisconsin

  • Across health and behavioral health care settings, there are many opportunities to identify and provide care to those at risk for suicide.

  • The Zero Suicide framework is a systemwide, organizational commitment to safer suicide care in health and behavioral health care systems.

  • 83% of those who die by suicide have seen a health care provider in the year before their death.21

  • To assist health and behavioral health organizations adopt the Zero Suicide framework, the Suicide Prevention Resource Center offers a free and publicly available online toolkit that includes modules and resources to address each of the seven elements of Zero Suicide. The toolkit is available at: https://zerosuicide.sprc.org/toolkit.

 

Voices From the Field

"From a project management standpoint, an organization cannot embark on this important work without a solid implementation plan. The Zero Suicide framework at zerosuicide.org sets the foundation to implement and sustain all seven components. Advocate Aurora Health is expanding the success of Zero Suicide from Aurora Sheboygan Memorial Medical Center to the entire enterprise—from Wisconsin to Illinois. "

– Becky Babcock, Performance Advisory Consultant, Advocate Aurora Health, Sheboygan

 

Another key aspect of this quality improvement framework is engaging people with lived experience of suicide (suicidal thoughts and behaviors or suicide loss). For an organization’s Zero Suicide implementation plan, one of the goals should be to have an implementation team that includes people with lived experience in developing, implementing, and evaluating efforts. A report from the National Action Alliance, The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from Lived Experience, offers a set of core values to inform suicide prevention and care, as well as specific recommendations for health and behavioral health care organizations and program developers.22

 

The Seven Elements of Zero Suicide

1.    Lead systemwide culture change aimed at suicide prevention.


2.    Train a competent and caring workforce.


3.    Identify patients with suicide risk via comprehensive screening.


4.    Engage those at risk using a suicide care management plan.


5.    Treat those at risk with evidence-based treatments.


6.    Transition patients through levels of care with warm hand-offs.


7.    Improve systems using data for continuous improvement.

 

21. Ahmedani, B. K., et al. (2014) Health care contacts in the year before suicide death. Journal of General Internal Medicine 29(6):870-7.

22. National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force. (2014). The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience. Washington, DC.

3A: Promote a systems change approach

Opportunities for Action Resources
Promote implementation of the Zero Suicide framework among Wisconsin health and behavioral health systems through training and use of the Zero Suicide Toolkit Wisconsin Zero Suicide Training
https://www.preventsuicidewi.org/zero-suicide
Zero Suicide Toolkit
https://zerosuicide.sprc.org/
Zero Suicide Research and Outcomes
https://zerosuicide.sprc.org/about/research-articles-outcomes
Encourage health providers and behavioral health systems to implement evidence-based and best practices in suicide prevention and suicide care management. Suicide Care Training Options—SPRC
https://zerosuicide.sprc.org/resources/suicide-care-training-options
CALM: Counseling on Access to Lethal Means
www.sprc.org/resources-programs/calm-counseling-access-lethal-means
Question, Persuade, Refer, Train (QPRT): Suicide Triage
www.qprinstitute.com
Preventing Suicide in Emergency Department Patients
https://training.sprc.org/enrol/index.php?id=8
Suicide in the Military PsychArmor Institute
https://psycharmor.org/courses/suicide-in-the-military
Encourage health and behavioral health care systems to engage people with lived experience of suicide attempts in planning suicide prevention efforts. Engaging People with Lived Experience
https://www.sprc.org/keys-success/lived-experience

 

 

3B

Expand the use of evidence-based screening, assessment, and suicide-specific treatments for those at risk.

 

Definitions:

  • 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.

  • Counseling on Access to Lethal Means (CALM): CALM is a free online course that focuses on how to reduce access to the methods people use to kill themselves. It covers how to identify people who could benefit from lethal means counseling; ask about their access to lethal methods; and work with them and their families to reduce access.

  • Safety plan: A safety plan is a prioritized written list of coping strategies and sources of support collaboratively developed by a service provider and a client who is at risk of suicide.

 

Access to evidence-based screening, assessment, and treatment is vital for preventing suicide in at-risk individuals. Therefore mental health, substance use, and health care providers must be equipped to identify and respond to individuals who may be suicidal. Evidence-based tools and resources should meet CLAS (Culturally and Linguistically Appropriate Services) Standards in order to reduce cultural barriers to receiving services. When providers can deliver services in this way, it leads to improved outcomes for clients.

From 2013–2017, 40% of people who died by suicide were currently in mental health or substance use treatment programs. (See Figure 49.) Individuals in these treatment settings can benefit from systematic and evidence-based screening, assessment, and treatment that will identify them as at risk and engage them in suicide-specific treatment.  In this way, behavioral health systems can help prevent suicide in their clients.

Primary and acute care health care settings can also play a role in preventing suicide in their patients by using an evidence-based screening tool to identify those with suicidal thoughts and behaviors, making sure those who screen positive receive a full assessment, and connecting patients with treatment, if needed.

 

 

In a Zero Suicide approach:

  • All people receiving care are screened for suicidal thoughts and behaviors at intake.
  • Whenever a patient screens positive for suicide risk, a full risk formulation is completed for the client.
  • All individuals identified to be at risk of suicide are engaged in a suicide care management plan.
  • The patient’s status on a suicide care management plan is monitored and documented in an electronic health record or paper record.
  • All clients with suicide risk, regardless of setting, receive evidence-based treatment to address suicidal thoughts and behaviors directly, in addition to treatment for other mental health or substance use issues.
  • Clients with suicide risk are treated in the least restrictive setting possible.

 

John R., a farmer from Argyle, Wisconsin, talked openly about his experience of losing his son and dealing personally with suicidal thoughts. He has found counseling to be the key to taking care of his mental health.

Voices From the Field

"On the subject of counseling, there should be no fear to admit that you have problems, need to deal with them, and need help expressing them and improving yourself. A failure to do so can put you and everyone you love at risk. "

– John R., Argyle, WI

 

Effective suicide care management is a health care strategy. For the strategy to be effective across various at-risk populations, the care must meet CLAS Standards. National CLAS Standards state that a principal goal in health care is 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. Effective suicide care management is a health care strategy. It must be responsive to diverse cultural health beliefs and practices for various at-risk populations.

3B: Support implementation of evidence-based screening, risk assessment, and treatment

Opportunities for Action Resources
Encourage health care settings to adopt recommended standard care to better identify and support people who are at an increased risk of suicide. The National Action Alliance, Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe
https://theactionalliance.org/healthcare/standard-care
Encourage providers to use evidence-based screening tools to screen for suicide risk. Columbia Suicide Severity Rating Scale (C-SSRS)
http://cssrs.columbia.edu/
Encourage providers to use evidence-based safety planning as an intervention for suicide prevention. Safety Plan Template—Stanley-Brown
https://www.sprc.org/resources-programs/patient-safety-plan-template
Safety Planning Intervention for Suicide Prevention, New York Office of Mental Health and Columbia University
http://zerosuicide.sprc.org/sites/zerosuicide.sprc.org/files/sp/course.htm
Encourage providers to engage in discussions with people at risk, and a person’s self-selected support network, about access to lethal means. Counseling on Access to Lethal Means (CALM)
http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means
Encourage behavioral health providers to practice evidence-based treatments that address suicidal thoughts and behaviors directly. Assessing and Managing Suicide Risk (AMSR)
http://www.sprc.org/training-events/amsr
Chronological Assessment of Suicide Events (CASE)
https://suicideassessment.com/certification-programs/
Cognitive Therapy for Suicide Prevention
https://www.sprc.org/resources-programs/cognitive-therapy-suicide-prevention
Collaborative Assessment and Management of Suicidality (CAMS)
https://cams-care.com/
Dialectical Behavior Therapy (DBT)
https://behavioraltech.org/
Recognizing & Responding to Suicide Risk (RRSR)
http://www.suicidology.org/trainingaccreditation/rrsr
Encourage providers to adopt the National Culturally and Linguistically Appropriate Services (CLAS) Standards. Wisconsin Department of Health Services National CLAS
Standards webpage
https://www.dhs.wisconsin.gov/minority-health/clas.htm
Federal HHS Think Cultural Health
https://thinkculturalhealth.hhs.gov/clas
Encourage providers to include a person’s self-selected support network in all aspects of the person’s care. Promote Social Connectedness and Support
https://www.sprc.org/comprehensive-approach/social-connectedness

 

 

3C

Improve care transitions for people with suicidal thoughts and behaviors who are discharged from emergency departments or inpatient settings.

 

Definitions:

  • Caring contacts: These are brief communications with patients during care transitions, such as discharge from treatment, or when patients miss appointments or drop out of treatment. These contacts can promote a patient’s feeling of being cared for and increase their participation in collaborative treatment.

  • Warm hand-off: A warm hand-off is when an existing provider connects the patient to a new provider, for example by being with the patient when they make an initial appointment, rather than simply providing them with the name and phone number of the provider. The goal of a warm hand-off is to increase the likelihood that a patient will follow up with recommended care.

 

The risk of suicide attempts and death is highest within the first 30 days after a person is discharged from an emergency department or an inpatient psychiatric unit of a hospital. This high-risk time of transition is often attributed to a lack of continuity of care after discharge. Recently, research has suggested that this one-month period immediately following discharge from a psychiatric inpatient stay should be regarded as a “distinct phase of care associated with an extraordinary suicide risk.”23

To improve care transitions and reduce risk, partnerships need to be developed between hospitals, including their emergency departments, and stakeholders in the community, such as county human services departments, community-based behavioral health providers, primary care providers, and community support organizations. In addition to warm hand-offs between care settings, patients should also be provided with crisis resources (e.g., local and national 24/7 crisis phone numbers and text lines) at the time of the transition, as well as an invitation to call the unit from which they are being discharged, if further assistance is needed. In these ways, caregivers and clinicians can help reduce the risk by bridging patient transitions from inpatient care or emergency departments to primary care, outpatient behavioral health care, or whichever setting the patient has chosen.

 

Voices From the Field

"Perhaps the issue is less the medium (letter, text, call, visit, postcard) than the contact. For someone who feels alone and perhaps of diminished value, or even a burden to others, the message can have a remarkable resonance. We often focus on the assumed value of the type of contact, and on who is the messenger. Some might think peer messages better, others focus on professional training, and others are sure that the medium is critical (e.g., a text can’t possibly be as good as something more personal). But maybe for many people who might be in a bleak space, it’s the simple message of caring and hope that has value. "

– Michael Hogan, Ph.D., Hogan Health Solutions (New York State Commissioner of Mental Health, 2007–2012)

 

The Zero Suicide approach for care transitions recommends that:

  • Organizational policies provide guidance for successful care transitions and specify the contacts and support needed throughout the process to manage any care transition.
  • Follow-up and supportive contacts for individuals on a suicide care management plan are tracked and managed using an electronic health record or paper record.
  • Patients are engaged in an individualized, culturally sensitive manner that takes into account their needs and preferences.
  • Staff are trained in how to provide supportive caring contacts and follow-up care using techniques, such as motivational interviewing, safety planning, warm hand-offs, and caring contacts.
  • Timely supportive contacts (e.g., calls, texts, letters, visits) should be standard at critical times, including after acute care visits, once a patient begins treatment, when a patient is in a higher risk period, or when services are interrupted (e.g., a scheduled appointment is missed).

23. Chung D, Hadzi-Pavlovic D, Wang M, et al. Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalization. BMJ Open 2019;9:e023883. doi: 10.1136/bmjopen-2018–023883.

3C: Improve care transitions

Opportunities for Action Resources
Encourage health systems to implement evidence-based practices to improve patient engagement and safety during the transition from inpatient to outpatient care. National Action Alliance, Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care
https://theactionalliance.org/resource/best-practices-care-transitions-individuals-suicide-risk-inpatient-care-outpatient-care
Encourage health care organizations to establish referral agreements between acute care settings and outpatient providers to ensure recently discharged high-risk patients have appointments within a reasonable timeframe. Safe Care Transitions
http://zerosuicide.edc.org/toolkit/transition
Encourage emergency departments to provide screening, patient education, discharge planning, and referrals to ensure continuity of care after discharge. Continuity of Care for Suicide Prevention: The Role of Emergency Departments
http://www.sprc.org/sites/default/files/migrate/library/ContinuityCare_Suicide_Prevention_ED.pdf
Encourage implementation of post-
discharge follow-up contacts with at
risk individuals.
Non-Demand Caring Contacts
https://zerosuicide.sprc.org/toolkit/treat/interventions-suicide-risk