1. . DSHS Grand Rounds

2. Logistics 2 Slides Slides are available on the GoToWebar website as well in the DSHS Lecture Hall. Registration questions? For registration questions, please contact Laura Wells, MPH at CE.Service@dshs.state.tx.us. For technical difficulties, please contact: GoToWebinar 1-800-263-6317(toll free) or 1-805-617-7000. Questions? There will be a question and answer period at the end of the presentation. Remote sites can send in questions throughout the presentation by using the GoToWebinar chat box or email GrandRounds@dshs.state.tx.us. For those in the auditorium, please come to the microphone to ask your question.

3. Disclosure to the Learner 3 Requirement of Learner Participants requesting continuing education contact hours or a certificate of attendance must: 1. register for the event; 2. attend the entire session; and 3. complete the online evaluation within one week of the presentation. Commercial Support This educational activity received no commercial support. Disclosure of Financial Interests The speakers and planning committee have no relevant financial relationships to disclose. Off Label Use There will be no discussion of off-label use during this presentation. Non-Endorsement Statement Accredited status does not imply endorsement by Department of State Health Services - Continuing Education Services, Texas Medical Association, or American Nurses Credentialing Center of any commercial products displayed in conjunction with an activity.

4. Peer-Reviewed Articles 4 Claassen CA, Harvilchuck-Laurenson JD, Fawcett J. Prognostic models to detect and monitor the near-term risk of suicide: state of the science. Am J Prev Med. 2014 Sep;47(3 Suppl 2):S181-5. Drum DJ, Denmark AB. Campus suicide prevention: bridging paradigms and forging partnerships. Harv Rev Psychiatry. 2012 Jul-Aug;20(4):209-21. Joshi SV, Hartley SN, Kessler M, Barstead M. School-based suicide prevention: content, process, and the role of trusted adults and peers. Child Adolesc Psychiatr Clin N Am. 2015 Apr;24(2):353-70. Milner A, Page K, Spencer-Thomas S, Lamotagne AD. Workplace suicide prevention: a systematic review of published and unpublished activities. Health Promot Int. 2015 Mar;30(1):29-37. Turecki G. The molecular bases of the suicidal brain. Nat Rev Neurosci. 2014 Dec;15(12):802-16.

5. Introductions 5 John Hellerstedt, MD DSHS Commissioner is pleased to introduce our DSHS Grand Rounds speakers John Hellerstedt, MD DSHS Commissioner

6. 6 Mike Hogan, PhD, President, Hogan Health Solutions; Past commissioner/director of mental health in New York, Ohio and Connecticut Zero Suicide: Not Another Life to Lose in Texas Molly Lopez, PhD, Director, Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas, Austin Jenna Heise, MA, BC-DMT, NCC, State Suicide Prevention Coordinator; Zero Suicide in Texas, Project Director, DSHS

7. Zero Suicide (Suicide Safe Care) in Healthcare: Background, Concepts and Practice Texas State Health Services Grand Rounds April 2016 Mike Hogan, PhD EDC ©2016. All rights reserved. 7

8. Health Care Progress Measured by Death Rates

9. National Action Alliance for Suicide Prevention Launched Sept 2010

10. Action Alliance Clinical Care and Intervention Task Force Access at: www.zerosuicide.com EDC ©2016. All rights reserved.

11. What Did We Learn About Suicide and Health Care Settings? Most suicide deaths are among people in care or recently seen in healthcare –S–Suicide prevention must become a core responsibility of health care organizations and systems We have new knowledge about detecting and treating suicidality. Very little of it is commonly used. –T–The gap between what we know and what we do can be fatal. We must apply new knowledge Preventing suicide deaths in health care requires a systematic clinical approach, not “the heroic efforts of crisis staff and individual clinicians.” –W–We have work to do EDC ©2016. All rights reserved.

12. Suicide and Health Care Settings 45% of people who died by suicide had contact with primary care providers in the month before death. Among older adults, it’s 78%. 19% of people who died by suicide had contact with mental health services in the month before death. South Carolina: 10% of people who died by suicide were seen in an emergency department in the two months before death. EDC ©2016. All rights reserved.

13. Suicide in Mental Health Systems Ohio: Between 2007-2011, 20.2% of people who died from suicide were seen in the public behavioral health system within 2 years of death. New York: In 2012 there were 226 reported suicide deaths among consumers of public mental health services, accounting for 13% of all suicide deaths in the state. Vermont: In 2013, 20.4% of the people who died from suicide had at least one service from state-funded mental health or substance abuse treatment agencies within 1 year of death. EDC ©2016. All rights reserved.

14. Patterns of Suicide in the “Mental Healthcare Neighborhood” Deaths in hospital are unacceptable, and rare –TJC: 1089 sentinel events reported 2010-2014 –NYS: Most suicide deaths in public mental health care (almost 80%) were among community care clients Of 17% classified as inpatient related, vast majority (85%) were within 30 days of discharge. Within 72 hours post-discharge: 2 times as many suicide deaths as on inpatient units 72 hours-30 days post-discharge: almost 4 times as many deaths as on inpatient units Improvements are needed in inpatient care (assessment, communication, treatment, transition) but the big challenges are in the community

15. WITHOUT IMPROVED SUICIDE CARE, PEOPLE SLIP THROUGH GAPS EDC ©2016. All rights reserved. Ask? Act for Safety? Treat Suicidality? Reduce Lethal Means? Engagement and Support?

16. THE TOOLS OF ZERO SUICIDE FILL THE GAPS

23. EDC ©2016. All rights reserved.

24. What Have We Learned About Suicide and Health Care Settings? Most suicide deaths are among people in care or recently seen in healthcare –Suicide prevention must become a core responsibility of health care organizations and systems We have new knowledge about detecting and treating suicidality. Very little is commonly used. –The gap between what we know and what we do can be fatal. We must apply new knowledge Preventing suicide deaths in health care requires a systematic clinical approach, not “the heroic efforts of crisis staff and individual clinicians.” EDC ©2016. All rights reserved.

25. A Systematic Approach to Health Care Quality Improvement: Henry Ford Health System EDC ©2016. All rights reserved.

26. Zero Suicide is… A focus on error reduction and safety in health care. A framework for systematic, clinical suicide prevention in behavioral health and health care systems. A set of best practices and tools including www.zerosuicide.com. Embedded in the National Strategy for Suicide Prevention and Joint Commission Sentinel Event Alert #56. A BHAG (Big, Hairy, Audacious Goal) EDC ©2016. All rights reserved.

27. 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. GOAL 9: Promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors. EDC ©2016. All rights reserved.

28. Joint Commission Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings “The suggested actions in this alert cover suicide ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow- up care of at-risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care.” EDC ©2016. All rights reserved.

29. Elements of Zero Suicide EDC ©2016. All rights reserved.

30. A Movement and a Mission EDC ©2016. All rights reserved.

31. Thank You EDC ©2016. All rights reserved.

32. DSHS Grand Rounds April 27, 2016 32 Creating Suicide Safer Care in Texas Creating Suicide Safer Care in Texas

33. Texas Deaths by Suicide: Rates per 100,000 33 CDC, Wonders

34. Texas Deaths by Suicide: Rates per 100,000 34 CDC, Wonders

35. Texas Leadership Statement 35 Zero Suicides in Texas is a commitment among Texas’ primary public health agencies to thoughtfully and systematically change the way we think about suicide prevention. The Texas Department of State Health Services and the Texas Health and Human Services Commission have undertaken the goal of advancing and actualizing patient safety for individuals receiving care through its public mental health system. No longer will we be thinking of prevention as fewer deaths, but rather no deaths.

36. The Learning Collaborative Held on a monthly basis with participating sites Focus on a specific zero suicide topic (e.g., risk assessment, safety planning, six month check in) – Corresponds with accompanying toolkit chapter Sites get to share success and challenges with each other – Lessons learned – Problem solving – Troubleshooting 36

37. Partners across Texas 37

38. Texas Toolkit Provides guidance and support to participating sites for implementation of the Zero Suicide framework Outlines goals for each core component and provides tools/resources to guide implementation activity https://sites.utexas.edu/zest/toolkit/ 38

39. Embedding the C-SSRS 39 Screening for all clients Evidence-based assessments Triage rules

40. Texas Training Plan 40 All Staff ASIST safeTALK ASK about Suicide Direct Providers C-SSRS Safety Planning CALM Specialty Providers CAMS CBT-SP

41. Impact of Workforce Training 41

42. Staff Practices and Confidence 42 All significant at p<.0001

44. Connect with Us! 44

45. Questions and Answers Remote sites can send in questions by typing in the GoToWebinar chat box or email GrandRounds@dshs.state.tx.us. For those in the auditorium, please come to the microphone to ask your question. Nina Jo Muse, MD Medical Director for Behavioral Health Texas Dept. of State Health Services

46. Upcoming DSHS Grand Rounds Presentation