Native American Rehabilitation Association of the Northwest, Inc.

Abstract: NARA (Native American Rehabilitation Association of the Northwest), an integrated primary and behavioral healthcare organization, located in Portland, Oregon, will launch a system transformation initiative by implementing the Zero Suicide model. The proposed project will implement suicide prevention and intervention programs at all NARA sites that serve adults 25 years of age or older. These sites include primary health and dental care, substance abuse treatment and mental health services. The proposed project will impact the NARA health system by consistently and systematically raising awareness of suicide, establishing effective screening, assessment, and referral processes, and improving overall care and outcomes for NARA patients who are 25 years and older. and at risk for suicide. The emphasis on adults, 25 years and older is important because it bridges the gap between existing NARA youth suicide prevention services whose focus has been youth and young adults 24 years of age and younger. The bridging of this gap is crucial for the health system because it allows for a more efficient, integrated and systematized perspective for suicide prevention and intervention. For the greater Portland area community, the proposed project brings much needed access to behavioral health services, a crucial gain for a city and state that rank very low for available behavioral health resources. The project will partner with Unity Behavioral Health Center, Portland’s only Psychiatric Emergency Room and Inpatient hospital for transitional care The Zero Suicide NARA project will provide prevention and intervention services to 750 Individuals each year of the project for a total of 3,750 participants over the five years. The project proposes to train 150 staff annually. Key interventions and strategies are: (1) create a leadership hub committed to reducing suicide among those in care at NARA; (2) development of a data-driven quality improvement approach to suicide care; (3) systematically identify, assess and monitor suicidality in the entire patient population; (4) systematic monitoring along a patient’s entire treatment pathway, for purposes of triage and indication for appropriate levels of acuity and intensity of care; (5) provide responsive family and community support to those at risk, those who have attempted and those who have survived. By adopting the Zero Suicide model, NARA seeks to reduce rates of suicidal ideation, suicide attempts and suicide deaths. Through system transformation, NARA commits to goals focused on increased suicide awareness activities and education; access to prevention, treatment; data reporting capacity; increased access to quality through continuous improvement; provision of targeted, evidence-based clinical interventions; and improved accessibility, follow-up and family/caregiver engagement.

Native American Health Center, INC.

The Native American Health Center’s Zero Suicide project will use a culturally competent, holistic care coordination model to reduce suicidal behaviors for AIAN and other underserved community members ages 25 and older living in the San Francisco Bay Area. Programing will strengthen organizational ability to effectively identity and treat community members at-risk for suicide by expanding suicide prevention, intervention, and behavioral health programing. Project activities will include the implementation of the Zero Suicide Model within NAHC’s suicide prevention framework. Project goals and measurable objectives are as follows:

Goal 1. Strengthen NAHC suicide prevention and treatment programming framework. Objectives include: 1. Provide 2 multi-departmental trainings in QPR and crisis intervention annually; 2. Engage suicide prevention projects across target populations thorough quarterly collaboration meetings; 3. Review and revise (if necessary) agency suicide prevention plan and disseminate findings using Zero Suicide Organizational Self Study annually; and 4. Enhance suicide assessment and treatment systems capability within NAHC’s E.H.R system in Year 1.

Goal 2. Strengthen NAHC’s treatment response to suicidal ideation and/or attempts for the target population by providing outpatient clinical behavioral health services. Objectives include: 1. Conduct screening, assessments, reassessments, and follow-ups to 1200 members annually; 2. Provide evidence based individual counseling and case management to 200 members annually; 3. Develop suicide care management plans for 200 members annually; 4. Provide internal referrals to substance abuse counseling and/ or mental health counseling services, prevention groups and recovery support services to 300 members annually; and 5. Provide rapid-follow-ups to 25 members annually.

Goal 3. Strengthen NAHC’s prevention response to suicidal ideation and/ or attempts for the target population by providing community based prevention services. Objectives include: 1. Provide community based suicide prevention outreach, support, at AIAN cultural events and activities to 500 members annually; 2. Provide intergenerational suicide prevention and recovery support group for 25 members annually; and 3. Engage 1-2 community volunteers to serve as program advisors. This project will use a variety of interventions including the NAHC developed Holistic System of Care for Native Americans in an Urban Environment; Question, Persuade, Refer Gatekeeper Training; Cognitive Behavioral Therapy, Dialectic Behavioral Therapy, and Eye Movement Desensitization and Reprocessing to 200 members annually and 1,000 members over the life of the project.

Montana State Department of Public Health and Human Services

Abstract: The Montana Department of Public Health and Human Services (DPHHS) is working with American Indian tribes and urban Indian health providers in our state to implement a Zero Suicide initiative targeted toward tribal and urban Indian communities for adults aged 25 and older. Montana has the highest suicide rate in the nation, and within our state, the American Indian suicide rate is greater than the general population. Our goal is to implement the Zero Suicide model using three tiers of implementation. Tier 1 will involve the implementation of Zero Suicide within two tribal communities wherein the tribe controls the majority of primary care and behavioral health resources. These tribes—the Confederated Salish and Kootenai Tribes, and the Blackfeet Nation—will govern the implementation of Zero Suicide within their delivery systems. Tier 2 will involve the implementation of the Zero Suicide model in communities where the tribes are significant ‘influencers’ of the primary care system, and provide critical behavioral health services and support. As ‘influencers’ these tribal partners will assert influence over the federal Indian Health Service provider systems serving their communities, and provide behavioral health treatment and support for those at risk for suicide. These tribes include Fort Belknap Tribes, Fort Peck Tribes, and the Northern Cheyenne Tribe. Tier 3 will involve the implementation of the Zero Suicide model in smaller urban Indian health organizations (UIHO) that provide limited primary care and critical behavioral health care. Coordination of care will be a major focus for the urban communities. The two urban Indian communities represented in Tier 3 are the Missoula Urban Indian Health Center in Missoula, MT, and the North American Indian Alliance in Butte, MT. Each tier accurately reflects the complexity of implementing a state-wide Zero Suicide model in Indian Country in Montana. Our State has worked with all tribes and urban Indian organizations to understand and implement Zero Suicide strategies—using evidence-based practices and best practices—to capture leadership buy-in, to train the workforce to be competent and confident in providing suicide care, to identify individuals receiving care that are at risk for suicide, to engage those individuals in safety planning or treatment, to transition individuals from treatment to home, and to improve suicide care within their systems as suicide care progresses. The Montana Legislature identified state resources to conduct statewide suicide prevention planning with tribes, and we will conduct a Zero Suicide Academy for 50 health and behavioral health care representatives from the 8 tribes and 5 urban Indian organizations across the state in October 2017. This grant will provide the needed support to fully implement the Zero Suicide model in each partner tribal and urban Indian community.

Missouri State Department of Mental Health

Abstract: Under the Zero Suicide Grant, the state of Missouri will integrate the Zero Suicide model into multiple health systems. This will be accomplished by 1) improving care coordination in emergency departments and hospitals, 2) strengthening the state’s crisis hotline system, 3) expanding Zero Suicide in its statewide behavioral healthcare system and its associated referrals systems, and 4) developing a statewide collaborative to guide policy and develop protocol for zero suicide prevention planning in Missouri. This project will serve 1) adults age 25 and older who have behavioral health disorders, 2) adults and their families experiencing crisis, and 3) Missouri veterans at risk but not currently served by the Veterans Health Administration. An intensive care coordination model will be piloted in Missouri’s two largest urban cities, Kansas City and St. Louis, through partnerships with local behavioral health providers and 18 hospitals/emergency departments. Missouri will provide direct service for over 1,100 adults in each of the project years – for a total over 5,500 over the course of the grant program. The state will strengthen its crisis hotline system by 1) increasing the number of Missouri crisis centers who are part of the National Suicide Prevention Lifeline network, 2) engaging and re-engaging crisis callers through use of a caring letter and/or postcard to provide compassionate encouragement for the individual to engage in follow-up care, and 3) training Missouri’s crisis hotline staff in engaging and communicating with military-connected people in a suicidal crisis. The state anticipates that its crisis hotline system will handle 15,696 calls -totaling of 47,088 calls over the grant period. Missouri will integrate the Zero Suicide model systemically by inviting behavioral healthcare, primary healthcare, and veteran services care providers to Zero Suicide Academies. Missouri will host a three-day Zero Suicide Academy during each year of the grant program. In addition, Counseling on Access to Lethal Means (CALM) trainings and train-the-trainer sessions will be provided to reduce access to lethal means among adults with identified suicide risk. Missouri will also increase the number of providers trained in Collaborative Assessment and Management of Suicidality (CAMS) to help manage suicide treatment. The Department of Mental Health will collaborate with other state departments and systems to establish a statewide coalition that will focus on suicide prevention. This coalition will be responsible for developing a state suicide prevention plan that is aligned with the Zero Suicide model, as well as the goals and objectives of the National Strategy for Suicide Prevention.

Iowa State Department of Public Health

Abstract: Every 20 hours a person dies by suicide in Iowa. Suicide is the second leading cause of death for 25-44 year-olds exceeded only by unintentional injury. Iowa has taken steps to implement effective suicide prevention strategies through previous funding opportunities and existing partnerships like the Iowa Suicide Prevention Planning Group. The Zero Suicide process will create suicide safe organizations across Iowa that will be better positioned to support clients at risk for suicide in a safe and least restrictive manner. The overall project goal is to improve the care and outcomes of individuals ages 25 years and older at risk for suicide, with the following specific project goals: Goal 1: Increase awareness of the risk for suicide among Iowa’s substance use disorder treatment population and treatment options. Goal 2: Enhance and expand the screening, treatment, and referral process for adults at risk for suicide. Suicide Iowa will begin with hiring key staff and introducing the 23 IDPH-funded substance use disorder treatment providers to the Zero Suicide model. At the same time, work will begin with Foundation 2 to develop a plan for technical assistance and follow-up services, and planning for the rollout of ASIST trainings. The Zero Suicide Academy will be held for approximately half of the IDPH-funded providers during the second project year with a Community of Practice following, with the other half participating in an Academy during project year 4. ASIST will be held for all providers during the first project year, and then offered annually to additional provider staff. The project proposes to serve the following number of Iowans over the five years of the project:

  • 85,000 people receiving substance use disorder treatment services will be screened for suicide risk, be linked to VA services (when applicable), and receive improved suicide safe services; and
  • 7,700 SUD treatment clients will receive enhanced follow-up care and transition services as they transition out of inpatient SUD treatment.

Cherokee Nation

Abstract: The proposed project is a partnership between Cherokee Nation Behavioral Health (CNBH) and suicide prevention experts from Johns Hopkins University to implement evidence based services to prevent suicide attempts and deaths. The project will take place in northeastern Oklahoma, which like other rural communities is high risk for multiple health disparities. The prevalence of suicide among Native Americans (NA) in Oklahoma was 10.5/100,000 between 2000 and 2014. However, these estimates provide an overall picture of the problem, determining the true prevalence of suicide among NAs is more complicated due to inconsistency of data and racial misclassification. Further, current screening procedures by Cherokee Nation Health System (CNHS) is likely leading to a vast underestimate of the actual suicide burden. The proposed project is being submitted to effectively, efficiently, and sustainably implement all seven elements of the Zero Suicide model to prevent suicide attempts and deaths. CN will implement the Zero Suicide model in all sites that comprise the Cherokee Nation Health System. The goals of the proposed project are to raise awareness, implement universal screening, track over time patients who screen positive for suicidality, and establish a high-quality, effective model of care for individuals at risk for suicide. These goals will be achieved by implementing evidence-based programs (EBPs) with strong research support and collecting a wealth of data that will increase the breadth, depth, and richness of the data to be leverage to create an incessantly improving learning healthcare system to cultivate a culture of life within CNHS. The CNBH-JHU partnership has chosen to combine the use of the three separate EPBs: 1) universal screening using the Columbia-Suicide Severity Rating Scale, 2) the White Mountain Apache Suicide Surveillance System, and the Collaborative Assessment for Managing Suicidality (CAMS). This multi-tiered and multi-faceted approach is absolutely critical to eliminating suicides from the CNHS. Further, the selection of a single EBP would not provide the breadth and depth required to fully integrate all seven elements of the Zero Suicide Model into the CNHS. The proposed project represents a passion for eradicating suicide and the selection of multiple EPBs is a testament of the CNBH-JHU partnership striving for this goal in full measure.

Choctaw Nation

The Choctaw Nation of Oklahoma is committed to integrating the Zero Suicide Model firmly into the tribal health system. Choctaw Nation Health Services Authority (CNHSA) will implement CNO Project Zero in an integrated health care system to provide prevention and intervention for individuals who are 25 years of age or older, to raise awareness of suicide, establish stronger referral processes, and improve the care and outcomes for individuals who are at risk for suicide. The target populations for Project Zero are:

1) approximately 1,200 American Indians age 25+ and their family members, who live within the 10½ county jurisdictional boundaries of the Choctaw Nation;
2) approximately 125 health providers who serve this population; and
3) 50 partner health providers in other county and state facilities.

A nurse will serve as project director to train the hospital medical professionals in QPR for Physicians, Physicians Assistants, Nurse Practitioners and Nurses. These trainings will build the capacity of the CNHSA to better identify and address patients who present with suicidal ideation/behaviors. The project director will travel to the nine other clinic sites for oversight, training and collaboration purposes, ensuring that all 10½ counties served by the CNO will benefit from increased suicide awareness, support services and that integration of Zero Suicide is implemented. Two integrated therapists will be hired to increase the therapeutic response to suicide, and will be based in LeFlore County at the CNHSA hospital and Pittsburg County at the second largest CNHSA Behavioral Health unit. They will operate out of Poteau and McAlester, Oklahoma. Choctaw Nation of Oklahoma is well positioned, and has already implemented some components that have been very well received.

The Zero Suicide model, a comprehensive, multi-setting approach to suicide prevention and intervention in health systems, will be the driving force of this project. CNO’s Project Zero will be inclusive of all elements of the Zero Suicide Model throughout the five-year funding cycle. We expect that the long-term impact will be the complete transformation of the Choctaw Nation Medical and Behavioral Health system to enhance our ability to identify, treat, refer, and ensure continuity of care for individuals at risk for suicide and suicidal behaviors. This project will follow the Choctaw concept of Achchukmali Imabachi Sa Banna, which describes a special caring – “teaching to make better”. This is the basis for the Project Zero. Caring and teaching/training are woven throughout as we build a system wide embrace of our people, our families, our providers and our community to intervene in, and reduce suicide.

American Indian Health and Family Services of Southeastern Michigan

Abstract: American Indian Health and Family Services of Southeast Michigan’s Collaborative Spirit of Hope, Wellness and Healing for our Community Project will serve American Indian/Alaska Natives, and other underserved adults, age 25 and above, in Southeast, MI. We will implement a ZERO Suicide Model to create a comprehensive health and behavioral health multi-setting approach to suicide prevention that addresses the 7 elements of the model to identify, treat, refer, and ensure continuity of care for individuals at risk for suicide, suicidal behaviors and substance abuse. The aim of our project is to prevent suicide deaths and the goals are to:

• Create a leadership-driven, safety-oriented culture committed to reducing suicide among people under care, and include survivors of suicide attempts and suicide loss in leadership and planning roles.

• Train and develop a competent, confident, and caring workforce.

• Identify and assess suicide risk and substance abuse among people receiving care.

• Engage individuals in ensuring that they have a pathway to care that is timely, adequately meets their needs, and includes a collaborative safety plan and means restriction.

• Treat with evidence-based treatments that target suicidal thoughts and behaviors.

• Transition to the provision of continuous contact and support, especially after acute care.

• Improve our system by applying data-driven, quality improvement approaches to inform system changes to lead to improved patient outcomes and care for those at risk.

Objectives are to: 1) Create an Implementation Team of leadership (N = 3); health and behavioral health staff and screeners (N = 8); suicide attempt (N = 5); and suicide loss (N = 5) survivors; 2) Train clinical staff in the Collaborative Assessment and Management of Suicidology (CAMS) approach (N = 10); and train non-clinical staff (via another grant project) in suicideTalk, safeTalk, Mental Health First Aide and Applied Suicide Intervention Skills Training to competently and confidently respond effectively in a caring manner to clients at risk; 3) Provide Hope and Wellness Suicide Screenings to new and existing patients in health and behavioral health, and in affiliate agency locations for suicide thoughts and behaviors (N = 200 annually, 1000 total); 4) Ensure clients assessed have a collaborative Suicide Care Management Plan (e.g. ongoing follow up assessments, safety plans, means restrictions) by designing policies and procedures to change systems, get staff buy-in, and implement and track this via EHRs (100% of those assessed at risk); 5) Utilize EPBs that target suicide risk to keep patients safe and thrive (Cognitive Behavioral Therapy, Motivational Interviewing, and CAMS); 6) Follow clients through all care transitions by implementing policies that include safe hand-offs to caregivers at AIHFS and upon discharge (100% follow-up); and 7) Use data to change the system to improve client outcomes and care for those at risk (ongoing).

Alabama Department of Public Health

The purpose of the Alabama Youth Suicide Prevention Program (YSPP) is to develop and implement statewide youth suicide prevention and early intervention strategies that will include collaboration among schools, educational institutions, juvenile justice systems, foster care systems, substance abuse and mental health programs, and other child and youth-supporting organizations. These activities and others will be utilized to reduce suicide deaths and non-fatal suicide attempts among adolescents in Alabama, ages 10-24, of all races and ethnicities. The Alabama Department of Public Health will partner with the Alabama Suicide Prevention and Resource Coalition, the University of Alabama at Birmingham, and five crisis centers located in North, North Central, Central, Southeast, and Southwest Alabama, that will serve as behavioral health service providers to provide services at the state level as well as the community level. The multifaceted approach will allow for multiple exposure and intervention methods as well as a larger degree of community engagement for Alabama’s youth population, which suffered from 11.7 suicides per 100,000 in 2013. 

The goals for the YSPP that are to be achieved by 2020 are to decrease the rate of adolescents (ages 15-24) who complete suicide from 11.7 to 9.2 per 100,000; decrease the percentage of high school students who seriously considered attempting suicide from 18.1 to 13.1 percent; decrease the percentage of high school students who made a plan about how they would attempt suicide from 14.3 to 13.8 percent; decrease the percentage of high school students who attempted suicide from 10.4 to 8.9 percent; and decrease the percentage of high school students who attempted suicide that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse from 3.6 to 2.1 percent. Because Alabama does not currently have data specifically addressing the 18-24 age range, questions will be added to the Behavioral Risk Factor Surveillance System to establish a baseline and capture the data. These goals will be achieved through a variety of efforts that will include both community and health systems components. Activities will include training 19,500 (3,500 the first year and increasing by 200 each subsequent year) Gatekeepers in community and hospital settings; providing prevention curricula to 17,500 (3,500 per year) teachers and students in schools; serving over 125,000 (25,000 per year) individuals through the operation of crisis hotlines, a referral network linking emergency departments and behavioral health service providers to ensure continuity of care for patients at-risk for suicide; and an action-based statewide education and awareness campaign based on the principles of safe suicide messaging. Both quantitative and qualitative measures of knowledge and educational efforts will be measured through de-identified, voluntary pre, post, and follow-up surveys to evaluate the performance of the program. To track program outcomes, all program activities will be monitored and evaluated throughout the duration of the grant.