1. Suicide Prevention: Collaborative Family Healthcare Can Lead
CFHA Conference. October 2016
Mike Hogan, Ph.D.
Nat’l Action Alliance for Suicide Prevention

2. Health Care Progress Measured by Death Rates

3. Suicide Prevention Issues in Health Care
Major strategies in Suicide Prevention since 1990:
Promote wellness: primary prevention
When feasible, the best approach. Very hard to get to scale
Means restriction
When feasible, effective. Also very hard to do on a broad scale
Improve identification and engagement in care for suicidal people (e.g. gatekeeper training)
Has an impact where it is done (GLS data). But also hard to do
A missing link: suicide prevention in health care:
A logical place to identify and help people is missing in action
The places suicidal people are sent if we do find them are generally not prepared to treat and keep them safe

4. Suicide Prevention in Health Care: Bad News and Good News
Most suicide deaths are among people in Health Care (HC)
But suicide prevention has not been a HC priority:
Evidence: where are the standards, measures, expectations?
Inpatient care: Joint Commission Sentinel Event Alert: 1996
Outpatient mental health: ?
Primary care: ???
Health plans: ????
And, currently there is no required training for health professionals, inadequate preparation for mental health professionals
The results are too often fatal

5. Suicide Prevention Issues in Health Care
Good news:
Effective tools are now established for screening, assessment, managing safety, treatment, follow-up
These effective tools are nearly all reimbursable, and can be implemented in ordinary settings with mental health staff
It works: systematic suicide care produces results
The tools are mostly publicly available
The Challenge:
Speeding up adoption of suicide safe care in a fragmented, distracted health system that wasn’t paying attention to suicide.
The story….

6. National Action Alliance for Suicide Prevention Launched Sept 2010

7. Action Alliance Clinical Care and Intervention Task Force
Access at:

8. Patterns of Suicide in the “Mental Healthcare Neighborhood”
Deaths in hospital are unacceptable, but rare (only estimated 2% of suicide deaths)
NYS: Most suicide deaths in public mental health care (83%) were among people in community care
Of 17% classified as inpatient related, most (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

9. Suicide in Mental Health Systems
Ohio: Between , 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.

10. Suicide and Health Care Settings
45% of people who died by suicide had contact with primary care providers in the month before death (multiple studies). Among older adults, it’s 78% (Conwell).
South Carolina: 10% of people who died by suicide were seen in an emergency department in the two months before death.

11. EDC ©2016. All rights reserved.
WITHOUT IMPROVED SUICIDE CARE, PEOPLE SLIP THROUGH GAPS
Support when it’s needed
Treat
Suicidality?
Zero Suicide Care Pathway
Reduce Lethal Means?
Engage, Act for Safety?
Ask?
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12. 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.” What happens with a systematic approach?

13. A Systematic Approach to Health Care Quality Improvement: Henry Ford Health System

14. EDC ©2016. All rights reserved.
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 (NEW): 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.
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15. 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.”

16. What are the Elements of Suicide Safe Care That Real World Innovators have Learned?
All the tools are at
Key clinical elements:
Assessing suicide risk for people with risk factors when they are seen
The most effective prediction of risk is asking people. Cf Simon et al., 2014
Simple questions like PHQ-9, Question 9 are effective
Assessment of risk also considers intent, plan. Consider e.g. Columbia Suicide Severity Rating Scale
The Safety Planning brief intervention (Stanley, Brown) is becoming the standard of care
Personalized, collaborative removal of lethal means of self harm is crucial (cf. Counseling on Access to Lethal Means—CALM)

17. What are the Elements of Suicide Safe Care That Real World Innovators have Learned?
All the tools are at
Key clinical elements:
Brief supportive contacts while people are vulnerable are effective (best documented intervention, see Knesper, 2011)
All forms of contact appear helpful: calls, texts, letters, postcards, visits.
When? Post-discharge or ED visit, in conjunction with missed appointment for a person with high risk, during any period of elevated risk
Direct treatment of suicidality is effective:
DBT, CT-SP, CAMS all have effectiveness, require therapists plus training
Promising: co-led suicide care groups
Implementation takes work, e.g. training, embedding clinical elements in workflow/EMR, PI.

18. Resources Are 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.

19. Click on that component and you go to…
….a brief description is shown. In this case, it’s the “Train” section, which is about developing a confident, competent, and caring workforce.
Click on that component and you go to…
Resources are behind each “button” for that topic

20. Where We Are on Making Care “Suicide Safe”
Accelerating a “slow idea” (Gawande) Analogy: moving from siloed to Dual/Tri-Optic care
Organizations need leadership, support
Crucial role of champions
has all the tools
Support and advocacy are essential
Some elements needed for national success are still developing
Data/Research on ZS overall effectiveness…we have data on the elements
Policy support is growing (recent White House meeting, Obama and House budgets for 2017, Clinton Mental Health Plan)
We can’t let this take (the usual) 20 years!

21. A Movement and a Mission

22. Contact: dr.m.hogan@gmail.com
Thank You
Contact:
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23. Suicide Prevention Resource Center
5/27/2018
Suicide Prevention Resource Center
Promoting a public health approach to suicide prevention
The nation’s only federally supported resource center devoted to advancing the National Strategy for Suicide Prevention.