Every year more than 40,000 Americans die from suicide and suicide is the tenth leading cause of death in the United States (CDC, 2016). Over eighty percent of people who die from suicide have contact with health and behavioral health care providers in the year prior to their death and almost half saw a health care provider in the month before death (B. Ahmedani et al, Health Care Contacts in the Year before Suicide Death, 2014). The proximity of death by suicide to health care visits makes health and behavioral health care settings ideal for intervention.
Historically suicide prevention has been seen as the responsibility of inpatient psychiatric services or community-based prevention programs. In recent years this has begun to change. Suicide prevention has been redefined and re-conceptualized as an essential obligation of health care. The 2012 National Strategy for Suicide Prevention specifically calls for suicide prevention as a core component of health care services, with objectives pertaining to delivering care in the most collaborative, least restrictive settings; providing continuity of care for suicidal patients seen in emergency departments and inpatient settings; and training clinical providers on the recognition, assessment, and management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk. Last year, The Joint Commission Released Sentinel Event Alert 56: Detecting and Treating Suicide in ALL Settings (emphasis added). This alert aims to “assist all health care organizations providing both inpatient and outpatient care to better identify and treat individuals with suicide ideation.” New York State’s Suicide Prevention Plan calls for statewide implementation of an approach called Zero Suicide, including all seven elements of the Zero Suicide model:
- Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people receiving care.
- Develop a competent, confident, and caring workforce with suicide-specific expertise.
- Systematically identify and assess suicide risk among people receiving care.
- Ensure every person has an individualized pathway of care, including safety planning with lethal means reduction.
- Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors.
- Provide continuous contact and support, especially after acute care.
- Apply a data-driven quality improvement approach to inform system changes.
Zero Suicide is a comprehensive approach to suicide prevention in health care where the entire system shares the challenge and responsibility of caring for suicidal patients instead of relying on the heroic efforts of crisis staff and individual mental health clinicians. Zero Suicide is an aspiration, a rallying cry, and the only acceptable goal.
The Institute for Family Health, a Federally Qualified Health Center network in New York State, was an early adopter of the Zero Suicide framework and we have committed to continuously improving care for our suicidal patients. Integral to our Zero Suicide efforts is leveraging strategic elements of electronic health record (EHR) design to promote population management principles with regards to managing suicide risk across our system. This has included adding suicide risk to the problem list where it is visible alongside other health conditions and implementing a prominent visual indicator in the patient’s chart to alert all of the patient’s providers of the risk. This provides unrestricted access to suicide risk information in the EHR so that meaningful assessment and care for suicidal patients can occur with any health care provider, including non-behavioral health specialists (e.g. primary care, nutritionists, care navigators).
Zero Suicide will, by necessity, look different in every organization that takes up the charge. The Zero Suicide framework is flexible and applicable to various health and behavioral health care settings. For example, the framework does not dictate how staff should be trained or how suicide risk should be identified among patients, but instead allows each organization to address elements of the model according to the unique needs and constraints of their service delivery settings. What must remain constant across all organizations is the unwavering commitment to progress towards Zero Suicide among patients receiving care.
During my graduate training I was fortunate enough to attend a lecture by D.A. Henderson, who led the global eradication of smallpox for the World Health Organization. After the lecture, a classmate asked Dr. Henderson what factor contributed most to the eradication. He could have cited the absence of a non-human vector, assuring that if the virus could be stopped in humans it would not continue in another insect or animal, or the heat-stable vaccine, which allowed it to be easily transported and administered across the globe. But he did not. Dr. Henderson credited the eradication of smallpox to a small group of dedicated staff who didn’t know that it couldn’t be done. What can this teach us about suicide prevention? How would we design our health care systems differently if we didn’t know that suicide couldn’t be eradicated?
To improve suicide care, community mental health centers first must take an honest appraisal of how they currently care for suicidal patients. Does your organization’s staff truly believe that suicide is preventable? Has leadership made a commitment to keeping patients alive and helping them create lives worth living? Do you keep track of patients at risk for suicide so they do not fall through the many cracks within and between health care organizations?
Visit www.zerosuicide.com for more information about the Zero Suicide framework, a self-study to assess your organization’s current provision of care to patient at risk for suicide, and implementation examples from other organizations.