The integration of primary care and behavioral health affords settings the ability to better identify and manage patients at risk for suicide. Each year in the United States 35,000 people die by suicide, a large majority of whom are not engaged in the mental health system and who saw their primary care provider within the month. With the suicide rates on the rise across New York, the time to develop better systems has never been more urgent. Integrated care settings provide opportunities for all disciplines to save lives through workforce training, the use of technology and established clinical pathways for patients at risk.
With the implementation and utilization of electronic health records, integrated settings have ways technology can help care for their population at risk for suicide. The development of decision supports as a reminder for screening and safety planning, “flagging” or specialized banners to identify patients and imbedding tools for assessment and risk, are critical steps that should be a priority for integrated care organizations as they develop their electronic systems. Even the placement of suicide risk on the problem list, which will draw attention to the risk by placing the problem in every provider encounter, is a way integrated settings can begin to use technology to care for their at-risk patients.
Unfortunately, thus far training systems have not adequately trained providers, of either behavioral health or primary care, to adequately address the needs of patients at risk for suicide. Continued use of antiquated “contracts” in many settings is a prime indicator that current workforces need to be trained in patient-centered and evidence-based approaches to the care and treatment of individuals at risk for suicide. Primary care providers feel un-equipped to ask, especially in a fifteen-minute visit with patients who have multiple chronic medical illnesses. Likewise, behavioral health providers often lack the “clinical confidence” needed to assess for suicide. Integrated settings offer the opportunity to train primary care providers to ask the right questions, identifying patients who would not have been previously identified as at risk, and then conducting a “warm hand off” to behavioral health or asking the behavioral health provider to join the visit to engage the patient in care, in a setting they identify as their clinical home. Equally critical to training primary care providers to ask the right questions and reinforce safety planning is having a behavioral health workforce that is adequately trained to manage patients at risk for suicide. A behavioral health provider trained in Assessing and Managing Suicide Risk (AMSR), XXXX (CAMS), specialized Cognitive Behavioral Therapy (CBT) or Dialectical Behavioral Therapy (DBT) has the tools to treat patients at risk. The combination of trained providers in an integrated setting can mean the identification of those patients who are currently completing suicides not being identified in primary care or engaged in behavioral health treatment.
Integrated settings offer the ability to develop truly comprehensive clinical pathways to identify and treat patients at risk for suicide. Organizations who develop a screening process to help identify patients can clearly define a process, involving all disciplines, for the care and management of patients at risk for suicide. A clearly defined workflow is critical not only for staff clarity, but for the prevention of patients at risk “falling off the radar”. All staff in integrated settings can play a role in the management of patients at risk and have a place in the pathway. A team approach, the availability of providers of all disciplines, the ability for joint visits involving both primary care and behavioral health, and shared records common in integrated settings allow for the development of comprehensive clinical pathways for patients at risk.
The diversity of staff in integrated settings offers a unique opportunity to identify and treat patients at risk for suicide in a way that could effectively decrease the numbers of individuals who die by suicide each year. Through leveraging technology, training the workforce and developing clinical pathways, integrated care organizations could provide the ability to identify patients seen in primary care settings not previously identified as well as engage patients in behavioral health services previously not known to or engaged in behavioral health services. Integrated care settings, or those moving on a path to developing an integrated setting, should prioritize the identification and treatment of patients at risk for suicide. The ability to save lives offers a clinical crisis providers of all disciplines can recognize and rally around. As organizations strive for improved internal systems around suicide prevention the setting as a whole will advance, further creating a truly integrated care system for all patients, making sure to include those at risk for suicide.