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

2. 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. 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

4. NYS Plan Strategy #3: Better Use of Data

5. 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?

6. 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?

7. 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 , 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

8. Outpatient Clinics: Suicide Count by Duration of Care
NIMRS Q – 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***

9. 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!

10. 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 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

11. 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

12. Making
New York a Model
Zero Suicide State

13. NYS Plan Strategy #1: Zero Suicide

14. 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

15. 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

16. 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

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

18. The Joint Commission: Sentinel Event Alert #56 February 2016

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

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