Zero Suicide implementation during a behavioral health crisis

While communities find a new way to live with the COVID-19 pandemic, the behavioral health crisis has intensified. Spectrum Health, a 14-hospital health system with approximately 2,671 providers in its western Michigan medical group, has seen a 100% increase in outpatient behavioral health needs, a 30% increase in pediatric behavioral health inpatient discharges, and a 10% increase in ED visits related to suicide attempts from 2019 to 2021.

In Michigan, overdoses increased more than 12% from January through August 2020 compared to the same period in 2019.1 With behavioral health needs on the rise, preparing and implementing Zero Suicide principles in medical group practices saves lives.

A study of the 2003 Hong Kong SARS outbreak’s impacts demonstrated increased suicide rates, specifically among older adults.2 Examination of suicide rates during the Spanish Flu pandemic in 1918 also showed an increase in suicide deaths, as social isolation and fears likely contributed to the rise.3 Initial investigations into the immediate and long-term impacts of COVID-19 reflect decreased suicide deaths and attempts4 but demonstrate elevated levels of adverse mental health conditions, substance use, and suicidal ideation.5 Given historical rises in suicide rates during and after previous pandemics and the alarming trends of increased ideation during the COVID-19 pandemic, healthcare organizations must proactively identify and address suicidal ideation among their patients and within their communities.

One method is implementing or augmenting Zero Suicide principles in medical group practice settings. Studies show that 83% of patients who die of suicide present within the healthcare setting a year before their death.6 Providing adequate access to behavioral health services remains challenging, thus Spectrum Health knew that it wanted to establish clear guidelines for addressing suicidality across all care settings. Due to so many patients having trusting relationships with their primary care providers, this was a natural place to start.

The Zero Suicide framework contains seven core elements (Figure 1) to provide safe care for individuals with suicidal thoughts and urges. These elements represent a holistic approach to suicide prevention applicable to health and behavioral health care systems.7

Spectrum Health began its journey to become a Zero Suicide organization with the adoption of universal screening across primary care practices, meaning patients 12 years and older are screened via a suicidality care pathway at every primary care visit unless they have been seen in the previous two weeks (Figure 2). Figure 3 shows volumes of screening growth from 2017 to 2021 as our processes became more embedded.

To align with the Zero Suicide framework, Spectrum Health developed the Blue Envelope (BE) program as a suicide risk response protocol for ambulatory settings. The BE serves as a code word to staff identifying a potential risk for suicide. A physical and electronic envelope is located within practices and within the EHR containing tools and resources to support teams in addressing suicidality among patients. The tools are broken out by Level 1 (support staff) and Level 2 (providers and behavioral health professionals) and detail team members’ roles in keeping the patient safe, administering proper interventions, and connecting the patient to appropriate services. The BE protocol emphasizes that suicide prevention is everyone’s responsibility and focuses on implementing S.A.F.E. steps when potential risk for suicide is identified.

• Stay with the patient. Room the patient immediately and designate a team member to remain with the patient until a Level 2 provider is available.
• Access help. Suicide is everyone’s responsibility. Team members should reach out to colleagues for assistance and support as needed. All team members are necessary in identifying, supporting and treating patients with suicidal ideation.
• Feelings — validate them. Thank the patient for their honesty and express that you are glad they told you how they feel.
• Eliminate risk. Ensure that the patient is placed in a room with minimal risk to accessing lethal means and has no harmful items on their person.

Spectrum Health learnings by element

Lead — Lead system-wide culture change committed to reducing deaths by suicide

Zero Suicide programming at Spectrum Health began with piloted screening for anxiety, depression and suicidality in a few primary clinics. Endorsement from department leadership grew the pilot to 10 clinics. Eventually, buy-in from executive leadership allowed the program to become more cohesive, and planning began to develop infrastructure for each element in the continuum. The medical group’s COO announced the organization’s full commitment to Zero Suicide via a system-wide memo to all employees, development of a video blog, and incorporation of “healing the whole person — mind, body and spirit” — as a critical priority for the system’s strategy. This garnered attention from stakeholders across the entire system and promoted increased collaboration to further develop system-wide suicide prevention programming. Without this public commitment to Zero Suicide, there was a critical challenge of resource and stakeholder prioritization to the work. This increased commitment and collaboration fostered the development of a Zero Suicide Expert Improvement Team (EIT) in which clinical and operational leaders utilize a multidisciplinary team approach to approve care pathways and system programming.

Key takeaway: Attaining endorsement for Zero Suicide at the highest executive levels paves the way for prioritization of element implementation across the organization.

Train — Train a competent, confident and caring workforce

The initial rollout of the BE program included in-person training by Spectrum Health’s suicide prevention team. As the program grows and annual refresher training is needed, we have pivoted to online training modules which can be assigned annually to large groups. Spectrum Health developed three training modules:

• Introduction to suicide prevention: Overview for all employees regardless of role or location regarding the importance of suicide prevention, why suicide prevention is everyone’s responsibility, how to identify someone with suicidal ideation, and resources for seeking care.
• Team member Blue Envelope: Developed for leaders and human resource employees addressing suicidal ideation among team members focusing on special confidentiality considerations and system employee resources available.
• Care of the suicidal patient: Intended for patient-facing team members providing a refresher of Spectrum Health’s policies and procedures regarding assessing and treating patients with suicidal ideation.

Key takeaway: Develop training appropriate to audience to reduce training fatigue.

Identify — Identify individuals with suicide risk via comprehensive screening and assessment

In 2016, primary care practices implemented universal depression and anxiety screening via the PHQ-4, initiating the development of our suicidality care pathway (Figure 2). In 2019, the Spectrum Health Zero Suicide EIT was formed to review suicide screening research and best practices. After also consulting with Zero Suicide program leaders, the EIT developed and implemented policies to utilize the PHQ-4 and the PHQ-9 Question 9 (suicidality question) as a universal suicide pre-screener within all primary care practices at visits for patients 12 and older. For every positive PHQ9-Q9, the Columbia-Suicide Severity Rating Scale (C-SSRS) is completed to assess for suicide risk.

These evidence-based tools were chosen in multidisciplinary groups who assessed efficacy, ease of use and peer-reviewed evidence. To encourage process compliance and completion of these tools, a best practice alert (BPA) fires for providers when a patient screens positive for suicidal ideation recommending the initiation of the Blue Envelope Protocol and completion of a suicide risk assessment.

Key takeaway: Develop a suicidality clinical pathway in multidisciplinary groups to maximize buy-in and ensure evidence-based versions are built in your EHR.

Engage — Engage all individuals at risk of suicide using a suicide care management plan

Involving the patient in their care plan is essential to any suicide response protocol. We decided on the Stanley Brown Safety Plan system wide to maintain standard, evidence-based practices across the continuum. Based on the C-SSRS calculated risk, recommended interventions display via a BPA. The BPA includes recommendations specific to the patient’s assessed suicide risk and includes a range of interventions, including: safety plan completion, mental health referrals, adding suicidal ideation to the patient’s problem list, initiating visual surveillance, considering petition for hospitalization, and/or facilitating immediate mental health evaluation.

Key takeaway: Develop risk-specific management plans to guide standardization of care.

Treat — Treat suicidal thoughts and behaviors directly using evidence-based treatments

The journey to proactively screen for suicide risk in primary care included many questions regarding the additional time needed to appropriately care for patients who screen positive. Much time and effort were dedicated to attaining buy-in and investment to place behavioral health specialists (BHSs) within primary care practices. These BHSs — clinical master level social workers (LMSWs) — provide care coordination and short-term psychotherapy to the patients associated with the office. These positions are critical to help primary care providers navigate suicidality assessments, treatment plans and transitions of care while ensuring that delays for other scheduled patients are minimized. Any patients requiring more long-term psychotherapy or psychiatry are appropriately referred for services. Investments to augment these services was secured to ensure demands could be met. Patients who are assessed at low risk are often treated within the primary care setting through lethal means reduction, safety planning, patient education and continued follow up.

Key takeaway: Invest in treatment personnel to ensure patients can attain care they need.

Transition — Transition individuals through care with warm hand-offs and supportive contacts

Spectrum Health developed a transitions of care workflow involving daily reporting of behavioral health-related admissions, discharges and transfers. Social workers within our primary care and outpatient psychiatry practices receive these reports and complete outreach calls to establish follow-up care and ensure patients’ needs are met post-discharge. Urgent outpatient psychiatry visit appointments are held for ED and inpatient discharges for quick access to ensure patient stabilization continues.

Patients who have suicidal ideation are provided with a carefully crafted treatment plan. One of the early decisions made across the system is to ensure all care settings have access to the behavioral health care plan and utilize the same evidence-based tools across care settings, minimizing the need for reassessment when patients transition from one setting to another. Many local behavioral health organizations also use the same tools making care coordination seamless.

Key takeaway: Utilize the same evidence-based tools across settings and build transition reporting so next setting of care is prepared to receive the patient.

Improve — Improve policies and procedures through continuous quality improvement

Since Spectrum Health’s initial commitment to becoming a Zero Suicide organization, feedback from clinical teams, analysis of clinical outcomes and review of process compliance have been assessed to optimize workflows and implement program enhancements. Through this analysis and continued EIT reviewal we have learned how compliance with guidelines can be challenging in very busy practices with many competing priorities and how embedding tools and workflows into the EHR can help foster quicker adoption.

Key takeaway: Identify data tracking and compliance mechanisms early and establish clear pathways for quality improvement decisions.

Conclusion

If your organization has not yet begun Zero Suicide programming or you see a need to expand, now is a great time to invest in these lifesaving efforts. Working in healthcare offers us the unique opportunity to intervene and offer hope to those who are struggling with suicidality. 

Notes:

1. Michigan Department of Health & Human Services. “Trends and Disparities in 2020 Overdose Deaths.” Michigan Overdose Data to Action Data Brief. May 2021. Available from: bit.ly/3NuYJOy.
2. Cheung Y, Chau P, Yip P. “A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong.” International Journal of Geriatric Psychiatry. May 23, 2008. Available from: bit.ly/36kURip.
3. Sher L. “The impact of the COVID-19 pandemic on suicide rates.” QJM: An International Journal of Medicine. October 2020; 113(10): 707-712.
4. Sinyor M, Knipe D, Borges G, Ueda M, Pirkis J, Phillips M, Gunnel D, the International COVID-19 Suicide Prevention Research Collaboration. “Suicide Risk and Prevention During the COVID-19 Pandemic: One Year On.” Taylor & Francis Online. Aug. 23, 2021. Available from: bit.ly/3uxWaCK.
5. Czeisler M, Lane R, Petrosky E, Wiley J, Christensen A, Njai R, Weaver M, Robbins R, Facer-Childs E, Barger L, Czeisler C, Howard M, Rajaratnam S. “Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24-30, 2020.” Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Aug. 14, 2020. Available from: bit.ly/3wz4Pam. 
6. Ahmedani B, Simon G, Stewart C, Beck A, Waitzfelder B, Rossom R, Lynch F, Owen-Smith A, Hunkeler E, Whiteside U, Operskalski B, Coffey J, Solberg L. “Health Care Contacts in the Year Before Suicide Death.” Journal of General Internal Medicine. June 29, 2014. Available from: bit.ly/36mPPlw.
7. Zero Suicide Institute. “Framework.” Zero Suicide. Feb. 7, 2022. Available from: bit.ly/3utPXYn.