Zero Suicide/Suicide Safe Care: Making Suicide Prevention a Core Responsibility of Health Care Mike Hogan--National Action Alliance on Suicide Prevention Spokane WA. March 2015

How Did We Get Here? National Action Alliance for Suicide Prevention The National Action Alliance for Suicide Prevention is the public-private partnership advancing the National Strategy for Suicide Prevention. Vision: The National Action Alliance for Suicide Prevention envisions a nation free from the tragic experience of suicide. Mission: To advance the National Strategy for Suicide Prevention (NSSP) by: Championing suicide prevention as a national priority Catalyzing efforts to implement high priority objectives of the NSSP Cultivating the resources needed to sustain progress Established: September 2010 Leadership: Co-Chairs: Public Sector Co-Chair: The Honorable John M. McHugh, Secretary of the Army Private Sector Co-Chair: Robert W. Turner, Senior Vice President - Corporate Relations, Union Pacific Corporation (Photo from launch of NSSP)

Why an Action Alliance for Suicide Prevention? WHO guidance: need National Strategy, and national guidance and leadership group First National Strategy for Suicide Prevention— 2001. Annual deaths increased 28% by 2012 Need to update the NSSP: New tools and evidence...largely unused Health care as a focus The National Action Alliance for Suicide Prevention is the public-private partnership advancing the National Strategy for Suicide Prevention. Vision: The National Action Alliance for Suicide Prevention envisions a nation free from the tragic experience of suicide. Mission: To advance the National Strategy for Suicide Prevention (NSSP) by: Championing suicide prevention as a national priority Catalyzing efforts to implement high priority objectives of the NSSP Cultivating the resources needed to sustain progress Established: September 2010 Leadership: Co-Chairs: Public Sector Co-Chair: The Honorable John M. McHugh, Secretary of the Army Private Sector Co-Chair: Robert W. Turner, Senior Vice President - Corporate Relations, Union Pacific Corporation (Photo from launch of NSSP)

New Knowledge: Better Treatment Saves Lives Slide from David Jobes

Clinical Care Task Force Members Co-Chairs: David Covington, Mike Hogan Magellan Team: Shareh Ghani MD, Chris Damle, Gabriella Guerra, Christine Ketchmark, Roni Siebels, Gaye Tolman, Jose Abreu, Liz Smithhart, Cindy Wilkins SPCNY: Fred Meservey (lead author), Pat Breaux, Gary O’Brien, Cassandra Kahl Ed Coffey, MD, HFHS Lanny Berman, AAS Christian Comeau, Empact SPC Kate Comtois, UW Laurie Davidson, SPRC Holly Dixon, Crisis Response Network John Draper, Natl SP Lifeline David Jobes, Catholic U Richard McKeon, SAMHSA Meredith Mechenbier, Com. Bridges Jill Robinson, SE Network Paul Schyve, MD, TJC Shannon Skowronski, US Admin. Aging

Clinical Care and Intervention Task Force Zero Suicide concept and model: Clinical Care Task Force, 2011 Advocates, survivors, clinicians, researchers Key concepts: Suicide takes place among people in health care and can be prevented there Much has been learned about suicide care since 2000, but most of it is not used Let’s apply what we know to make health care suicide- safe Let’s test its feasibility in health and behavioral healthcare Rapid growth in membership: More than 200 diverse organizations, supported by Suicide Prevention Resource Center staff Selection and advancement of four priorities (2012)

Shifts in Perspective From: Someone else’s job Staff pessimism and withdrawal Individual provider work; suicide care a “specialty” Training and other single "solutions" Episodes of crisis To: A fundamental responsibility of health care organizations Rational optimism, and engagement A shared commitment with tools and supports A comprehensive approach to a chronic health condition Continuity of caring

Suicide Among Health Care Patients Is A Problem Half of the people who die by suicide were in GP's care, seen in prior year, 25% seen by GP in previous month South Carolina: 10% of all suicide deaths were people seen in ED in previous month People receiving care in mental health system: Risk among people with depression and other mental health problems up to 20x general population Kentucky: 25%+ of all suicides among people with MH care Vermont: 24% of all suicides among people with MH care NYS: 226 reported suicides in public MH system in 2012 (13% of estimated 1700 deaths in NYS)

Health Care is Not Suicide-Safe Take Concrete Steps for Safety, or… Send them home Suicidal Person Continuity of Caring, or Refer and Hope Screen, Assess for Suicidality… Or “Don’t Ask, Don’t Tell’ Treat Suicidality, or Commit to Hospital Care and Hope for the Best Serious Injury or Death

Systematic Suicide Care Plugs the Holes in Health Care Suicidal Person Collaborative Safety Plan with Lethal Means Restriction Treat Suicidality: Suicide-Informed CBT, Groups, DBT, CAMS Screen, Assess for Suicidality Excellent Access, and Follow-up Contact after ED, Inpatient Death or Serious Injury Avoided

The Power of a Systematic Approach : HFHS Launch: Perfect Depression Care These data are from a large health maintenance organization (HMO) serving about 200,000 members. at baseline, they had an annual rate of 89 suicides per 100 000 members They implemented a quality improvement effort known as the Perfect Depression Care program in the Behavioral Health Services (BHS) division Within 4 years, the suicide rate had decreased by 75%

2012 National Strategy for Suicide Prevention: GOALS AND OBJECTIVES FOR ACTION A report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention GOAL 8. Promote suicide prevention as a core component of health care services. Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal by health care and community support systems that provide services and support to defined patient populations. Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide risk in the most collaborative, responsive, and least restrictive settings. Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide. Objective 8.4: Promote continuity of care and the safety and well-being of all patients treated for suicide risk in emergency departments or hospital inpatient units. Objective 8.5: Encourage health care delivery systems to incorporate suicide prevention and appropriate responses to suicide attempts as indicators of continuous quality improvement efforts. Objective 8.6: Establish linkages between providers of mental health and substance abuse services and community-based programs, including peer support programs. Objective 8.7: Coordinate services among suicide prevention and intervention programs, health care systems, and accredited local crisis centers. Objective 8.8: Develop collaborations between emergency departments and other health care providers to provide alternatives to emergency department care and hospitalization when appropriate, and to promote rapid followup after discharge. GOAL 9. Promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors. Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of suicide risk among persons receiving care in all settings. Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice and continuity of care for providers who treat persons with suicide risk. Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by all patients. Objective 9.4: Adopt and implement guidelines to effectively engage families and concerned others, when appropriate, throughout entire episodes of care for persons with suicide risk. Objective 9.5: Adopt and implement policies and procedures to assess suicide risk and intervene to promote safety and reduce suicidal behaviors among patients receiving care for mental health and/or substance use disorders. Objective 9.6: Develop standardized protocols for use within emergency departments based on common clinical presentation to allow for more differentiated responses based on risk profiles and assessed clinical needs. Objective 9.7: Develop guidelines on the documentation of assessment and treatment of suicide risk and establish a training and technical assistance capacity to assist providers with implementation. GOAL 8: Promote suicide prevention as a core component of health care services. GOAL 9: Promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.

What is Different in Zero Suicide? Making suicide prevention (keeping our patients alive) a core responsibility of health care Systematic "Suicide Safe Care"...not a single, underpowered approach (e.g. a training session) Applying our new knowledge: Asking about suicidality among people with risk (screening) is a must Personal safety plans work. “No-harm contracts” do not Personal lethal means restriction is effective. Treatment and support for suicidal feelings is effective Supportive contacts help keep people alive While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., ... & Kapur, N. (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. The Lancet, 379(9820), 1005-1012.

The Clinical Dimensions of Zero Suicide Examples, evidence, and Options Mental Health Research Network report (Greg Simon et al.)— responses on Question 9 of PHQ- 9 DO predict suicide Reliability and feasibility established for Columbia Suicide Severity Rating Scale (C-SSRS) Assessment: more than screening. To find ways to manage risk, not just classify it Clinical elements ASK (Screen, assess)

The Dimensions of Zero Suicide Clinical elements Collaborative Safety Plan

The Dimensions of Zero Suicide Clinical elements Remove Lethal Means

The Clinical Dimensions of Zero Suicide Evidence-based treatment and support for managing suicidal feeling as well as mental illness/substance use: Collaborative Assessment and Management of Suicidality (CAMS) Competent clinical staff trained in Assessing and Managing Suicide Risk (AMSR) Dialectical Behavior Therapy Suicidality-informed Cognitive Behavioral Therapy Plus…Peer support Sustained engagement of people with significant suicidality during treatment, and during periods of risk/transition

Experience and Learnings: Zero Suicide It can be done. Successful implementation in behavioral health and integrated primary care Implementation is hard work The tools are available; putting them in place takes work Different challenges and opportunities at different stages It takes a team, leadership, a planned approach, CQI We have evidence, not proof: Not acting is unacceptable: People are dying in usual care There is good evidence behind all the clinical elements of ZS: Screening, Safety Planning, Means Restriction, Targeted Treatment, Supportive Contacts Early adopters are approaching Henry Ford results

Experience and Learnings: Zero Suicide Early adopters are approaching Henry Ford results: Centerstone

Resources at: www.zerosuicide.com What is Zero Suicide? Basic information, including the 2-pager. For Champions Resources for advocates: Zero Suicide two-page description Short PowerPoint presentation with talking points about suicide care in health care systems Zero Suicide Organizational Self-Study Get Involved We offer several options for connecting with others who are passionate about making zero suicide a reality: Join the Zero Suicide Listserv Sign up for the Zero Suicide newsletter Attend one of our free webinars or watch the archives  Attend  in-person training events, such as conference presentations and the annual Zero Suicide Academy And webinars What’s New is upcoming events as well as the newest stories, resources, and tools. Get Technical Assistance goes to a web form so folks can sign up to get assistance from one of the team and our experts. Zero Suicide Academy is information about national, state, and regional Academies.

Toolkit landing page. Video that briefly describes the 7 core components. “Using the Toolkit” guide will be here. When you mouse over any of the 7 core components….

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