Implement Best Practices for Prevention in Health Care Systems

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.

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.

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

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

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.

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

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.

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