Jay Carruthers, MD & Sigrid Pechenik, PsyD Suicide Prevention Office September 12, 2016

Suicide: A Major Public Health Problem “From 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population.” NCHS Data Brief No. 241, April 2016, CDC Habituated to the steady increase: passed annual deaths by MVA, homicides, breast cancer

3 Core Strategic Domains of the Plan: Integrating a systemic approach to suicide prevention into the health and behavioral healthcare systems Community(non-clinical) interventions 3. Making better use of existing and new surveillance data

NYS Plan Strategy #3: Better Use of Data

Leveraging Existing Data Sets NIMRS/TJC PSYCKES/Medicaid SPARCS/H-CUP Vital Statistics SPARCS – unique in that it is all payer hospital database Others: EMRs, Community Prevention Measures, Managed Care?

Some NYS Assets for Data-Informed Suicide Prevention Better Suicide Surveillance and linking to QI initiatives in the public mental health system: NY entry into the National Violent Death Reporting System (NVDRS) linking data from death certificate, coroner/medical examiner reports, and police investigation PSYCKES application enhancements Pushing New York Incident Management Report System (NIMRS) alerts out to MHARS, PSYCKES Suicide Prevention Office reviewing community and state ops suicides Zero Suicide 101: No blame culture Linking(individual)tree and(population)forest data sets?

NYS (OMH) Surveillance Patterns: What We’ve Learned Most (~75%) NYS suicide deaths in public mental health care are among community care clients Of 17% classified as inpatient related, vast majority (85%) were within 30 days of discharge *From 2012-14, among Medicaid recipients that had an OMH (NIMRS) reported suicide death, claims w/in 30 days of death showed: nearly half, 47% (N=61) received outpatient mental health services 11% received Psychiatric ER or Medical ER services; and 5% Psychiatric Inpatient services Among those receiving mental health services w/in 30 days prior to death: most common diagnoses were mood disorder and schizophrenia most were receiving care in clinics (56%) and a 6 month look back period prior to death showed: median number of visits was 8 Mode was 3 visits We presume that NIMRS reporting varies by provider: outpatient care > inpt >> CPEP. So the NIMRS data reflect this bias. *Source: NIMRS and Medicaid OMH crosswalk analysis; Dual eligibles excluded from analysis

Outpatient Clinics: Suicide Count by Duration of Care NIMRS Q1 2013 – Q1 2015 DURATION OF CARE Total Count Percent of Total Under 1 Year 152 58% 1-2 Years 49 19% 3-4 Years 22 8% More than 5 Years 41 16% Grand Total 264 100% SUICIDES WITHIN 1 Year of Care SUICIDES INVOLVING CLIENTS WITH A DURATION OF CARE UNDER 1 YEAR Total Count Percent of Total Within 1 First Week of Admission 14 9% 1 to 2 Weeks 7 5% 2 to 3 Weeks 15 10% 1 to 3 Months 46 30% 3 to 6 Months 29 19% 6 to 9 Months 21 14% 9 Months to 1 Year 20 13% Grand Total 152 100% Among suicides in the first year, nearly 25% in care for < 1 month***

NYS Surveillance Patterns: Take Home Messages OMH surveillance data strongly suggests the greatest burden of suicidal patients falls on outpatient mental health providers, especially clinics. High proportion of suicides among those receiving clinic care occur early in the course of treatment Must be ready from day 1!

PSYCKES Suicide Prevention CQI Project Building Zero Suicide into the project architecture: Systematic personalized screening for increased detection Sound suicide risk assessment to guide treatment and engagement (planning and prevention, not prediction) High Risk Suicide Care Management Plan/Pathway Safety Plan Increased engagement and monitoring Individualized plan that targets drivers Workforce training provided by SP-TIE@CPI; Learning Collaborative to support culture change Monthly performance metrics for CQI throughout Project launch in Fall 2016: >180 clinics signed up to date! Zero Suicide

About What is PSYCKES? Who is in PSYCKES? A web-based platform for sharing Medicaid data and other state health databases. Nearly 7,000 users (BH clinics, hospitals, EDs/CPEPs, MCOs) Who is in PSYCKES? 6 million Medicaid enrollees with BH diagnosis, service, or psychotropic medication. What Client Information is in PSYCKES? Up to 5 years of Medicaid claims/encounter data: Behavioral health (outpatient and inpatient) Care coordination (ACT, Health Home, Care mgmt.) Pharmacy (psychotropic and medical) Medical (inpatient & outpatient services, lab tests, and procedures) Living Supports/Residential (Medicaid, state-operated, coming soon: shelter data) State Psychiatric Center data Before describing a project that will likely be the largest state lead implementation of Zero Suicide in the nation, it’s worth taking a moment to explain a little more about PSYCKES

Making New York a Model Zero Suicide State

NYS Plan Strategy #1: Zero Suicide

Zero Suicide Bedrock Principles Most suicide deaths occur among people recently seen or discharged from care. Suicide prevention must be core responsibility of healthcare systems New knowledge about detecting and treating suicidality is not commonly used. We must apply new knowledge to clinical practice Suicide prevention in healthcare requires a systematic clinical approach. Not “the heroic efforts of crisis staff and individual clinicians” Luoma J AJP 2002: ¾ individuals who died by suicide had primary care contact year prior to death; 1/3 MH contact 45% w/in 30 days for primary care; 1 in 5 for MH; rates vary by gender and age – Conwell study nearly 80% of >55 yo had primary care contact w/in 30 days of death *Slide adapted from Dr. Mike Hogan

Implementation of Zero Suicide Strategies Can Fill the Gaps Participation in the PSCKES Suicide Prevention CQI project will help clinicians: improve screening of suicidal clients; assist in what to do when someone screens positive; help with assessing risk and how to link risk to levels of intervention; help develop safety plans to help clients manage their suicidal feelings Adapted from James Reason’s “Swiss Cheese” Model of Accidents – EDC © 2016

PSYCKES CQI Project measures Proportion of clients with a (+) CSSRS screen with a safety plan entered into PSYCKES Proportion of current clinic census on the suicide care pathway (SCP) Proportion of clients seen weekly among those on the suicide care pathway. Acute Care Transition (seen for an appointment within 72 hours of discharge) Rate of Completed Suicide among ALL Clients Rate of Completed Suicide among those on the suicide care pathway. Suicide Attempt Rate among ALL Clients Suicide Attempt Rate among those on the suicide care pathway. Emergency Department Usage Inpatient Admissions -Measuring suicide safer care in its infancy but developing quickly -The field stands to learn a lot from what will likely be biggest implementation of ZS in the nation

Suicide Prevention Integration Into Regulatory Standards The Joint Commission SEA, Feb 2016 OMH Standards of Care Suicide Safer Care Report Care (to be developed)

The Joint Commission: Sentinel Event Alert #56 February 2016

NYS Plan Strategy #2: Community (non-clinical) Interventions

Q & A THANK YOU FOR YOUR TIME! Jay.Carruthers@omh.ny.gov Sigrid.Pechenik@omh.ny.gov