1. 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

2. 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)

3. 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)

4. New Knowledge: Better Treatment Saves Lives
Slide from David Jobes

6. 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

7. 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)

8. 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

9. 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 deaths in NYS)

10. 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

11. 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

12. 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 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%

13. 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.

14. 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),

15. 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)

16. The Dimensions of Zero Suicide
Clinical elements
Collaborative Safety Plan

17. The Dimensions of Zero Suicide
Clinical elements
Remove Lethal Means

18. 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

19. 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

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

21. 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.

22. 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….

23. Thank You!