1. Central Arizona Programmatic Suicide Deterrent System Project Dr. Laura Nelson, ADHS Medical Director & DBHS Deputy Director Don Erickson, ADHS Bureau Chief Adult and Children System of Care

2. “Suicide represents a worst case failure in mental health care. We must work to make it a ‘never event’ in our programs and systems of care.” - Dr. Mike Hogan President’s New Freedom Commission on Mental Health

3. “Over the decades, individual [mental health] clinicians have made heroic efforts to save lives… but systems of care have done very little.” - Dr. Richard McKeon SAMHSA Bureau Chief for Suicide Prevention

4. Source: * National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2009). Web-based Injury Statistics Query and Reporting System (WISQARS). Available from: www.cdc.gov/injury/wisqars/index.html. **Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 11-4667. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Pyramid of Suicidal Behaviors (US): More Common Than Thought

5. State (Lowest & Highest) Age-adjusted Rate (per 100k) New Jersey6.7 Montana22.5 Source: Centers for Disease Control and Prevention (CDC) vital statistics “Serious Public Health Problem”: More Common in West Region 1 #8 #4 #1 #3 #5 #9 #6 #9 #6 #2 11 12 13 14 15

6. Source: National Center for Health Statistics. Note: Non-Hispanic Ethnicity Suicide by Age, Race & Gender: Who is Highest Risk?

9.  Suicide Attempts: Female>>male Rates peak in adolescence Concern: Latina youth and LGBT > Suicide Deaths: Male : female = 4:1 Elderly white males -- highest rate Working aged males – 60% of all

10.  Group A > Group B

11. Arizona’s New Paradigm: Suicide Care & Intervention Shift in Perspective from:To: Accepting suicide as inevitableEvery suicide is preventable Stand alone training and toolsOverall systems and culture change Specialty referral to niche staffPart of everyone’s job Individual clinician judgment & actions Standardized screening, assessment, risk stratification and interventions Hospitalization during episodes of crisis Productive interactions throughout ongoing continuity of care “If we can save one life…”“How many deaths are acceptable?”

12. Arizona’s System of Care Framework  High Reliability – Aviation goal zero commercial crashes Don’t train only the pilots; instead, all procedures & systems target success  Health Systems – Eliminate: Wrong-site, patient surgery Inpatient falls Medication Errors  Crossing the Quality Chasm

13. I. Core Values & Beliefs  Current science: Suicide is preventable Those who die by suicide have intense ambivalence Caring saves lives  Last decade: Increased research on effective interventions Development of standardized risk assessments & standards Systems successes

14. II. Systems Management  Robust Performance Improvement Workforce Development Standardized Clinical Care Screening & Assessment Stratification of Risk Regimen of Key Interventions o Access to Care o Means Restriction o Follow-up Transparent Reporting & Feedback Loops, Commitment to Improvement

15. III. Evidence Based Clinical Care  “Productive Interactions” – Therapeutic relationships based on engagement and collaboration  Treat suicide risk directly (not just underlying diagnosis)  Evidence based care  Involuntary hospitalization is minimized, considered a safety measure and possible sign of community care defects

16. Accountability for Results: Lives Saved  Timely public reporting of suicide deaths Measure & Report Feedback Loop

17. 1.All-staff Suicide Intervention Training (ASIST) 2.Attempt Survivor Peer Support Groups 3.Standardized Screen, Assess, Stratify and Intervene 4.Family Engagement 5.Review Past 100 Deaths 6.Member Awareness, Outreach & Follow-up

18. More than 2,400 staff trained Continued training of new staff at all sites Suicide Prevention and Intervention Model Validation Detailed interventions and support strategies Working collaboratively with providers and stakeholders to identify potential risk factors & predictive characteristics Participation, venue, frequency Evidence based program Examples Social Support History Family Supports Suicide History Length of Care Family History of Suicide Best practice review: HFHS, Harvard & Suicide Care in Systems Framework Assessment categories -high, medium and low risk Screening tools developed – adult, adolescent & child Competitive RFP, selection process, awards, implementation Working with peer run organizations to increase participation. Developed a family engagement training with NAMI Finalizing Family Welcome Packet with Community Resources Case Analysis of 100 suicide cases (2009-2011) Substance Use Willing to Accept Help Medication/TX Adherence Hospitalization/Crisis Use Co-morbid conditions Recent Stressors Incorporated into new employee orientation

19. Suicide Care Is Everyone’s Business

23. Saving Lives Saving Money: Case Examples

24. Reduction in Suicide Death Rates

25. National Action Alliance (2010): Zero Suicide in Healthcare Initiative

26. Task Force Report Suicide Care in Systems Framework Arizona Authors: A national task force was convened to develop the framework and 14 of 29 authors were from Arizona and the Programmatic Suicide Deterrent System Project

27. Replication in Other States: Arizona’s Workforce Survey State# Responses Arizona 20091,666 Arizona 20101,813 Georgia 20101,562 Texas 20123,621 Pennsylvania 2012August 2012 Kentucky 2012Fall 2012 New York 2012Fall 2012 Total To Date8,662

29. Thank you! Questions or Comments?