Michael F. Hogan, PhD, Commissioner of the New York State Office of Mental Health co-chairs the Clinical Care and Intervention Task Force of the National Action Alliance on Suicide Prevention. In August of 2011 the Task Force completed a sweeping report entitled “Suicide Care in Systems Framework.” Together with twenty-eight leaders from across the nation, Dr. Hogan and the Task Force provide important new recommendations on suicide care.
According to Commissioner Hogan, “The National Action Alliance on Suicide Prevention was launched on World Suicide Prevention Day in September 2010 by Cabinet Secretaries Sibelius and Gates. It is an impressive array of public and private sector leaders committed to save lives; the co-chairs are (former) Sen. Gordon Smith and New York’s own John McHugh, Secretary of the Army. I am honored to co-lead (with David Covington of Magellan) a high-energy Task Force on suicide prevention in clinical settings (health and behavioral health care). On studying the problem and what we have learned in the decade since publication of the first National Strategy on Suicide Prevention, our Task Force came to a simple but profound conclusion: dramatically reducing suicides by an accretion of small steps (e.g. better training, screening or awareness) is almost impossible. Suicide takes place in desperate isolation, and reaching people through better small steps just won’t do it. On the other hand, we now have breakthrough examples of how organizations committed to save lives across entire populations they are responsible for, have done just that.”
“The best-known example is of course the well-studied commitment of the U.S Air Force Suicide Prevention Program. There clearly are examples in colleges and universities, like Cornell’s thoughtful program. But we focused on examples in health care, including the Central Arizona Programmatic Suicide Deterrent System Project and the Henry Ford Health System (HFHS) “Perfect Depression Care” effort. We found that these systems adopted a systematic “do whatever it takes” approach. Top leadership made a commitment. Measurement and performance improvement were “baked into” the effort. And lives were unquestionably saved.”
“We were especially inspired by what we learned about HFHS. Motivated to strive for “Six Sigma” or even perfect care for depression, the HFHS team came to decide that losing ONE LIFE to suicide is unacceptable. What more profound measure of good behavioral health care could there be? The HFHS leadership are aware that achieving ZERO SUICIDE might not yet be possible, but that’s their goal. And they are committed to robust performance improvement, and a culture of safety that does not seek blame if problems occur. HFHS has now gone for over two years without a known suicide death in their population under care.”
“Our message in the Clinical Care Task Force Report is that piecemeal approaches are no longer enough. These might make the participants feel better, and we might even save a few people. But we now have the technology (from screening for risk, to evidence-based treatments, to suicide awareness training, to performance improvement, to follow-up pioneered by the national Lifelines program run by the Mental Health Association of NYC) to begin to work toward ZERO SUICIDE. We are looking for health and behavioral health systems to join in this movement. We ask…how many deaths are acceptable, anyway?”
“We hope this summary of our work encourages you to work toward a commitment in your community or health care organization.”
In each of the initiatives we studied, dramatic successes were achieved in reducing suicide attempts, deaths, and in reducing costs associated with unnecessary hospital and emergency department care. Most importantly, these initiatives have demonstrated the capacity to save lives. In reviewing these initiatives, the Task Force found three critical factors common to all that led to their remarkable successes.
- Core Values – the belief and commitment that suicide can be eliminated in a population under care (boundaried population), by improving service access and quality and through continuous improvement (rendering suicide a “never event” for these populations);
- Systems Management – taking systematic steps across systems of care to create a culture that no longer finds suicide acceptable, set aggressive but achievable goals to eliminate suicide attempts and deaths among members, and organize service delivery and support accordingly; and
- Evidence-Based Clinical Care Practice – delivered through the system of care with a focus on productive patient/staff interactions. These methods (e.g., standardized risk stratification, targeted evidence-based clinical interventions, accessibility, follow-up and engagement and education of patients, families and health care professionals) achieve results.
Core Values: Beliefs and Attitudes the Foundation for Eliminating Suicide Deaths and Attempts
The Task Force has identified five critical elements that it believes are instrumental for public and behavioral health organizations to adopt and adapt in order to implement suicide prevention effectively.
- Leadership leading to cultural transformation – Organizational leadership must articulate and infuse the fundamental tenet that a suicide event (attempt or death) is an unacceptable outcome of its care, and build a culture that strives to make suicide a “never event.”
- Continuity of Care and Shared Service Responsibility – Caring for suicidal persons requires that the suicidal risk be addressed directly, not merely as a symptom of an underlying disease. That care will most likely require multiple levels of services in a team environment. Discharge decisions from one level of care (e.g., hospital care) must incorporate linkages to other necessary levels of care (e.g., intensive outpatient, private therapist, pharmacological therapy). Organizations must recognize, accept, and implement shared service responsibilities both among various clinical staff within the organization and among providers in the larger community.
- Immediate Access to Care for All Persons in Suicidal Crisis – Because many persons seek care only when they are in crisis, behavioral health systems must provide 24-hour, 7-day a week availability to individuals trained in assessment, supportive counseling and intervention. Crisis hotlines, online crisis chat/intervention services, self-help tools, crisis outreach teams and other services can ensure that individuals can obtain help when they need it – eliminating barriers related to cost, distance, and stigma.
- Productive Interactions between Persons at Risk and Persons Providing Care – Positive health and behavioral health outcomes are partly dependent on a functional relationship between the person requiring help and the persons delivering help. This assistance should respect the cultural preferences and values of the individuals as much as possible. Trusting therapeutic alliances are fundamental to reducing suicide risk and promoting recovery and wellness. Such alliances are most productive when the care is collaborative, where the client is actively engaged in making choices that will keep him/her safe, and when the clinician feels confident that he/she has the training and skills to support the client’s safety and treat the suicide risk.
- Evaluate Performance and Use for Quality Improvement – Setting a goal of zero suicides and managing a system of care to achieve that goal requires organizations to evaluate performance rigorously and to use untoward events as opportunities to improve their capacity to save lives at risk.
Systems Management: Implementation and Action for Care Excellence
To achieve the goal of zero suicides will require countless managerial decisions – both the major policy shifts and the details of patient care management. In this context, the Task Force recommends three major managerial areas to guide the organization of effective service delivery.
- Policies and Procedures – All health and behavioral health organizations should have specific written policies and procedures focused on the detection and response to persons presenting for care with suicide risk. Staff must be trained on how to employ the policies and procedures, with regular (e.g., annual) scheduled refreshers.
- Collaboration and Communication – Responding to suicide risk should be premised on collaborative care characterized by direct and open communication with persons at risk of suicide and timely and effective communication patterns with all personnel who are collaborating in the person’s care.
- Trained and Skilled Work Force – Public health and behavioral health organizations should assure that staff working with persons with suicide risk have been appropriately trained and possess requisite skills.
Evidence-Based Clinical Care Practice: Comprehensive Quality Care to Save Lives
While research has shown that over 90 percent of persons who die by suicide had a diagnosable mental health disorder and/or substance use disorder, empirical research has shown that it is insufficient to treat only the mental disorder. In contrast, the extant literature does show that targeting and treating suicidal ideation and behaviors, independent of diagnosis, hold the greatest promise for care of suicidal risk. It is vital that direct intervention and treatment be provided for potential suicidality. Care for persons at risk of suicide should be person-centered, where their personal needs, wishes, values, and resources become the foundation of developing a plan for their continuing care and safety. Where appropriate and practical, families and significant others should be engaged and empowered as well. Cultural values and preferences should be respected as much as possible. The Task Force has identified the following four components of care.
- Screening and Suicide Risk Assessment – Universal screening for suicide risk should be a universal part of Primary Care, Hospital Care (especially emergency department care), Behavioral Health Care, and Crisis Response settings (e.g., help lines, mobile teams, first responders, crisis chat services). Any person who screens positive for possible suicide risk should be formally assessed for suicidal ideation, plans, availability of means, presence of acute risk factors (including history of suicide attempts), and level of risk.
- Intervening to increase coping to ensure safety – All persons identified as at risk of suicide by primary care practices and clinics, hospitals (esp. emergency departments), behavioral health organizations and crisis services should have a collaboratively designed safety plan prior to release from care. This should include inquiring about means access and planning to restrict access to lethal means (balanced with respect to other obligations, including legal and ethical requirements under federal and state laws).
- Treating and caring for persons at-risk of suicide – Treatment and support of persons with suicide risk should be carried out in the least restrictive setting using research-guided practice techniques.
- Follow Up – Persons with suicidal risk leaving intervention and care settings should receive follow-up contact from the provider or caregiver.
To read the entire Task Force report, go to http://actionallianceforsuicideprevention.org/wp-content/themes/twentyten/images/pdfs/taskforces/ClinicalCareInterventionReport.pdf.
Visit the National Action Alliance on Suicide Prevention website at http://actionallianceforsuicideprevention.org/.