University Health System San Antonio

The University Health System Zero Suicide program will implement a comprehensive, multi-setting suicide prevention and intervention approach under the framework of the seven essential elements of the Zero Suicide Model. In partnership with University Medicine Associates (UMA), the Health System aims to reduce suicide attempts and deaths among adults, 25 years and older, especially veterans and individuals with serious mental illness. Population: The Zero Suicide Program will screen 300,000 adults, 25 years and older, including veterans and individuals with serious mental illness, who are at-risk for suicide across 21 ambulatory clinics, including specialty care clinics, in five regional areas. Of these 300,000 it is estimated 5,400 will screen positive for suicidality. Zero Suicide Model: To ensure the successful implementation of the Zero Suicide model, an implementation team, including survivors of suicide, will build upon the strengths and weakness identified by the Zero Suicide Organizational Self-study and embed the seven elements of the Zero Suicide Model across the five regional clinic areas in yearly phases. In conjunction, the Zero Suicide Data Elements Worksheet will be utilizing to develop a data-driven, quality improvement approach to maintain fidelity and improve care, training, and policies. Goals and Objectives: The overall purpose of the Health System’s Zero Suicide program is to raise awareness, establish referral processes, and improve care and outcomes for patients at risk for suicide by creating a leadership-driven, safety oriented culture.

Measurable objectives are to:
(a) To transform the health system by implementing the Zero Suicide model, establishing an implementation team, and providing training to all UMA staff;
(b) Improve care and outcomes for patients at risk for suicide by enhancing the EMR and providing evidence-based treatment;
(c) Identify and engage patients at risk for suicide by increasing screening, comprehensive assessment, and safety planning; and
(d) ensure continuity of care by increasing formal agreements with community behavioral health.

St. Vincent Hospital/Health Care Center (INDNPLS)

Abstract: The Ascension Zero Suicide Collaborative Network is a multi-state, 27-site partnership that will reduce suicide deaths by 40% by transforming primary care, behavioral health, medical/psychiatry, OB/GYN, residency clinic and emergency department services. It will serve 265,000 individuals 25 years and older in diverse urban and rural settings. 2,000 people will be trained in suicide prevention techniques. Special outreach will focus on U.S. Veterans, people with substance use disorder, middle aged men, pregnant moms, individuals with social determinants of health barriers and other under-served populations. Ascension, the largest nonprofit health system in the US, its national Ascension Behavioral Health Steering Committee and its national Ascension Behavioral Health Affinity Group will create a leadership-driven culture that embraces recovery and the principles of Zero Suicide. Ascension is committed to delivering compassionate, personalized care to all with special attention to persons living in poverty and those most vulnerable. The purpose of the Ascension Zero Suicide Collaborative Network is to raise awareness about suicide, develop a safety-oriented culture, create robust referral processes and significantly improve care and outcomes for people who are at risk for suicide. A Zero Suicide Survivor Advisory Group will be created to ensure survivor leadership and input. The Network will implement all components of the Zero Suicide model throughout diverse settings and create an implementation guide and lessons learned that will be shared with organizations within and beyond Ascension. State Zero Suicide Champions will ensure alignment with state suicide prevention plans/committees and actively collaborate with state and local health agencies via regular updates and meetings. Primary care and emergency department professionals will have access to virtual simulations in order to practice identifying and engaging people at risk of suicide. People receiving care in primary care, emergency departments, OB/GYN clinics and other key settings will be screened using the PHQ-2 and where indicated, the PHQ9. If there is an indication that the person may be at risk for suicide, the individual will receive an assessment using the Columbia Suicide Severity Rating Scale. When an individual is identified as being at risk, they will be enrolled in the Ascension Zero Suicide Clinical Pathway and will be engaged in Suicide Care Planning and Collaborative Safety Planning including Counseling on Lethal Means (CALM). Individuals on the pathway will receive treatment for suicidal thoughts and behaviors in the least restrictive, most appropriate level of care. Mental health therapists will be trained on Assessing and Managing Suicide Risk (AMSR). Caring follow-up will occur to ensure engagement and effective transitions of care. People discharged from the hospital after a mental health crisis will be called within 48 hours after discharge. Regular reassessments will indicate when someone no longer needs the clinical pathway.

South County Hospital Healthcare System

Abstract: The Washington County (Rhode Island) Zero Suicide Program (WCZSP) will be led by South County Hospital Healthcare System’s (SCH) Emergency Department (ED), drawing on the strong collaboration that SCH leads for the county’s Healthy Bodies, Healthy Minds program. The effort will begin in our local hospital EDs since the ED is a typical entry point for patients at imminent risk for suicide. The EDs will receive evidence-based training and practices to enhance their skill sets and change their culture to empower them to better address the behavioral health needs of the county’s population. During the project period, we will expand to other parts of the hospitals as well as to other health care organizations in our region. All individuals age 25 or older who seek health care at one of the partner sites will be screened for mental health issues using the PHQ-9, as many partners now do. Anyone identified at risk for suicide will receive immediate treatment or referral, a care management plan, and follow-up for one year post care. The Washington County population, per the US Census Bureau (2016), includes 84,360 individuals age 25 or older. Of these, 47.2% are male; 52.3% are female; 0.5% are transgender. The county is predominantly White (92.9%), with 2% Asian, 1.3% Black or African American, and 3.2% identifying as Hispanic or Latino. Washington County has the highest suicide rate in RI: 13.9 per 100,000 individuals (2015), higher than the national rate of 13 deaths per 100,000 population and increased from a rate of 11.5 in 2013, a more than 20% increase over two years compared to the national increase of 2% per year since 2006. Three of the five RI towns with the highest suicide rates are in the county, 23.8, 26.6, and 31.8 per 100,000 population, respectively. The WCZSP will apply a High Reliability Organization strategy to create a wide-spread ZS leadership-driven safety culture, using extensive evidence-based trainings and practices to provide all staff at partner organizations with the skills and confidence to take responsibility for suicide prevention to achieve zero suicides in the county by the end of the project’s fifth year. We will track the number of patients who screen positive for a suicide risk, patients evaluated in our hospital EDs for psychiatric inpatient admissions, patients seen by peer recovery specialists, patients referred to any form of support who do not keep their appointments, and patients who die by suicide. We will use qualitative methods to assess changes in attitudes toward zero suicide prevention by leadership and all staff who have patient contact, in provider confidence to effectively treat at-risk patients, and in patient and family perceptions regarding the efficacy of care and support received. We will use a suicide review board to investigate all suicides for root cause analysis and use rigorous data collection and analysis to create an ongoing quality improvement environment for the program. The number of individuals to be served each year: Year 1 – 9,789; Year 2 – 9,881; Year 3 – 9,913; Year 4 – 9,996; Year 5 – 10,107. The total population to be served over 5 years is 49,686.

South Carolina Department of Mental Health (SCDMH)

Abstract: The South Carolina Department of Mental Health (SCDMH) will implement the ZERO Suicide Initiative to reduce suicide attempts and deaths among South Carolina (SC) adults age 25 and older. SCDMH, the largest behavioral health provider with a vast footprint, will serve as the base and build on established as well as future relationships to reduce deaths by suicide in SC. Based on what we know about populations at the greatest risk for suicide in SC, the ZERO Suicide Initiative will ramp up efforts to serve anyone suspected of being at risk, with a specific focus on the following subpopulations: white males, veterans, law enforcement/first responders, and the homeless population. The project will increase the ability of organizations, agencies, and individual professionals to provide coordinated, responsive, and effective rapid follow-up and aftercare to adults who have attempted suicide, as well as those who are assessed as being at risk of suicide. To work with collaborative partners on the SC State Suicide Prevention Coalition to make fundamental policy changes at a systemic level that support provision of excellent aftercare to suicide attempt survivors. Key goals of ZERO Suicide Initiative include but are not limited to: 1) To implement effective, evidence-based treatments that directly target suicidal thoughts and behaviors. 2) To strengthen and revise discharge protocols at emergency departments (EDs) and acute care psychiatric hospitals (ACPHs) to provide aftercare for at-risk adults age 25+. 3) To promote suicide prevention as a core component of healthcare services (NSSP Goal 8) through provision of training. 4) To promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors (NSSP Goal 9) through provision of training (Zero Suicide Academy) to health and behavioral health providers. 5) To embed suicide prevention strategies/activities into the behavioral health system. 6) To increase use of SC Lifeline by SC residents so at least 70% of calls remain in-state.

SMA Behavioral Health Services, INC

Abstract: SMA Behavioral Health Services, Inc., a four county behavioral health system, will utilize Zero Suicide funding to implement Adult Zero Suicide, a suicide prevention and intervention program for individuals 25 years of age and older, that raises staff awareness of suicide, establishes referral processes, and improves care and outcomes for individuals who are at risk for suicide. SMA will employ a full-time trainer to facilitate Question, Persuade, Refer (and Treat) (QPR) and (QPRT) training to all SMA staff across the organization’s four-county service area. QPR(T) is a SAMHSA NREPP intervention specifically designed to train staff on suicide prevention and intervention. Currently, all SMA staff receives QPR training, but frequency of trainings is limited. The full-time trainer will also provide QPR and QPRT trainings to staff members at local county jails. Training will also be provide to case managers at the Orlando VA Medical Center, local VA outpatient clinical staff in our four county services area, and psychiatric services staff at Halifax Health in Daytona Beach and Flagler Hospital in St. Augustine. SMA will engage and intervene with veterans at risk for suicide but not currently receiving VA services. The Department of Veterans Affairs (VA) is mandated to provide services for up to 90 days to any Veteran who presents to the VA as at-risk for suicide, regardless of whether or not the Veteran currently receives VA benefits. SMA and the Orlando and Jacksonville VA Medical Centers will coordinate services so that veterans without benefits can receive ongoing services and care coordination after the initial 90 days of VA services. As a Memorandum of Understanding currently does not exist between SMA and the VA, one will be created to define roles, expectations, and services between the two organizations. SMA will also work closely with other local VA services associated with all four counties. Adult Zero Suicide will, within the four county service region, employ four Care Coordinators who will provide behavioral health screenings, assessments, Suicide Care Management Plans, immediate care coordination and follow up with anyone leaving a Crisis Stabilization Unit, anyone involved with Veteran’s Affairs behavioral health services who is transitioning out of VA services, and those at risk of suicide upon release from county jails. SMA currently employs Care Coordinators who provide care to clients discharged from two of the three Crisis Stabilization Units (CSU) across its four-county system of care, but there is not enough of this resource to provide comprehensive care to all those at risk in the region. Adult Zero Suicide will integrate with systems that provide ongoing follow up care available in the community to prevent future suicide attempts and ensure proper follow up care has been accessed and utilized. The Suicide Care Management Plan will include protocols for safety planning, reducing access to lethal means, rapid follow up for those discharged from CSU, a VA facility or jail with suicidal thoughts/ behaviors, protocols to ensure client safety including outreach telephone contact within 24-48 hours after discharge and documenting the scheduling and attendance at appointments with a therapist and/or psychiatric provider within 48 hours of discharge. 1,000 individuals will receive Care Coordination services over the five year grant period.

Pueblo of San Felipe

Abstract: The purpose of the San Felipe Zero Suicide (SFZS) is to implement the Zero Suicide prevention and intervention program throughout the health care system in the Pueblo of San Felipe. The target population is San Felipe tribal members 25 years of age or older who are risk for suicide. The aim will be to raise awareness of suicide, establish screening, referral, and treatment processes, and improve care and outcomes for individuals who are at risk for suicide. By addressing all elements of ZS, health care providers in San Felipe will transform the health system to one that is ready to identify, treat, refer, and ensure continuity of care for individuals at risk for suicide and suicidal behaviors. The goals of SFZS are to:

(1) Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care;

(2) Develop a competent, confident, and caring workforce;

(3) Increase access to care;

(4) Engage survivors of suicide attempts and loss in leadership and planning; and

(5) Utilize an ongoing Continuous Quality Improvement framework to provide feedback aimed at improving the system.

Services provided will be universal screenings of all patients accessing health services, assessment, safety planning and referral to treatment for all those who screen positive for suicide, and treatment using evidence-based practices such as Cognitive Behavioral Therapy Suicide Prevention (CBT-SP) and Counseling on Access to Means (CALM). The unduplicated count of individuals served is broken up into 3 categories: training, screening and intervention. TRAINING. It is anticipated that 27 staff will participate in SFZS via training, including 19 clinical and non-clinical medical staff of the IHS Health Clinic (4 primary care physicians, 4 registered nurses, 1 patient registration staff, 1medical records/front desk staff, 1 nutritionist, and 1 diabetes educator in the medical clinic; 1 pharmacist, 3 pharmacy techs, and 2 contracted pharmacists in the pharmacy; and 2 dentists, 2 dental hygienists, 2 dental assistants, and 1 front desk staff in the dental clinic). In addition, 6 licensed behavioral health providers and 2 unlicensed behavioral health providers from the Behavioral Health Program will participate via training (4 independently licensed behavioral health providers, 2 substance abuse providers, 1 psychology doctoral level intern, and 1 psychiatrist). SCREENING. Based on the annual numbers served, it is anticipated that 2,000 patients will be screened annually at the primary care IHS Health Clinic. INTERVENTION. Based on national statistics that indicate that of 1.8% of patients screened in primary care settings are at high risk for suicide and 4.5% are at moderate risk, we anticipate a minimum of 25 patients participating in CBT-SP annually. We gradually increased this number over time as we believe we will have a higher rate of recruitment into SFZS over the years, as services become better known in the community. Thus, we anticipate 175 individuals participating in CBT-SP over the life of the grant.

Ohio Department of Mental Health and Addiction Services

Abstract: In 2015, 1,426 Ohioans aged 25 or older died by suicide and accounted for 86.4% of all Ohio suicide deaths. The suicide rates for Ohioans aged 25 and older was 18.05 compared to the U.S. rate of 17.68. Ohio’s data surveillance system, which currently consists of Ohio Department of Health (ODH) death certificate files and National Violence Data Reporting System (NVDRS) data, Medicaid service utilization data, and a state-wide gap analysis of available services throughout Ohio, indicates a need to develop a continuity of care model to treat suicide ideation by integrating behavioral health (BH) services with physical health (PH) services. The purpose of Ohio’s proposed project is to prevent suicide deaths and attempts among Ohioans ages 25 and older. Ohio’s project is intended to prevent suicide deaths and attempts among Ohioans ages 25 and older by focusing on the implementation of the Zero Suicide framework across the system of care. The system includes behavioral health organizations (BHO), primary care (PC) providers, crisis lines, and Veterans Administration (VA) outpatient clinics. BHOS include community-based BHOs and state-operated BH hospitals. The key priority areas are: 1) Leadership/Planning, 2) Care Coordination/Care Transition, 3) Screening/Assessment, 4) Safety Planning and Harm Reduction Counseling, 5) Treatment, 6) Prevention/Postvention Strategies, and 7) Workforce Development. Ohio’s project specifically addresses the implementation of the Zero Suicide framework’s seven components: lead, identify, engage, treat, transition, and improve. Broadly, in order to implement this framework, Ohio will attempt to attain the goals of increasing

1) collaboration among community partners about suicide risk for adults ages 25 and older;

2) BH and PC staff skills in identifying and treating at-risk adults;

3) rapidly transition of at-risk adults to treatment in the least restrictive setting;

4) number of at-risk adults who are identified and treated;

5) treatment and supportive service adherence;

6) improved access to treatment and supportive services, including support groups; and

7) use of evidence-based and promising practices.

With the involvement of a state and local advisory boards, the Ohio Department of Mental Health and Addiction Services will partner with three BH organizations (BHOs), Coleman Professional Services, Consolidated Care Inc. and Hopewell to serve 13,324 individuals. Key activities to achieve project goals include the implementation of a care coordination/transition model that will involve linkages with hospitals, ERs, crisis lines, FQHCs, and the Veterans’ Administration Community Outreach clinics. Staff across the system of care will be trained on how to identify, screen, assess, and treat at-risk adults; linkages will occur among BHOs, hospitals, ERs, FQHCs, VA community outreach clinics, and crisis lines; and collaboration with the local Boards, suicide prevention coalitions, and survivors will result in public awareness campaigns. The project emphasizes evidenced-based and/or best practices including Cognitive Therapy for Suicide Prevention, Dialectical Behavioral Therapy, and Collaborative Assessment and Management of Suicidality. These EBPs were selected with the goal of increasing the number of at-risk adults receiving treatments specific to suicidal thoughts and behaviors, are appropriate for adults receiving treatment in BH settings, promote timely access to assessment, intervention, and effective care for at-risk individuals.

New York

The New Yorkers Advancing Suicide Safer Care (NYASSC) project will reduce suicide attempts and deaths by implementing Zero Suicide (ZS) in health systems across all five mental health service regions in New York. The project will also create a Suicide Safer Care Network in a high-risk county by linking emergency departments, inpatient psychiatric units, outpatient mental health and substance use disorder treatment settings, and primary care practices to create a local zero suicide safety net. The project anticipates assessing 281,596 individuals served by the project sites for suicide risk over five years, and projects that of those assessed, 197,116 will receive suicide-specific interventions. The Office of Mental Health will partner with the Center for Practice Innovations at Columbia University and the University of Rochester to advance implementation of Zero Suicide across the state. Providers will develop competency in the NYS Suicide Safer Care Model which includes screening and assessing for suicide risk, developing a prevention-oriented risk formulation, suicide care management plan, providing suicide specific evidence-based treatment and brief interventions, and protocols for transition of care and follow up when patients move to a different level of care.

The four goals of the project are to:
1) implement Zero Suicide in health systems in each of the five regions of NYS,
2) develop a Suicide Safer Care Network across all health systems in one high risk county,
3) disseminate statewide implementation of Zero Suicide based on lessons learned at project sites in the first 3 years of the grant, and
4) evaluate the project’s impact on clinical service delivery and utilization and on suicide attempts and deaths.

With input and guidance from individuals with lived experience and members of the NYS Suicide Prevention Council, project goals will be accomplished by accomplishing the following objectives: engaging health systems leadership, conducting learning collaboratives, training providers, developing and implementing site specific protocols, developing and conducting fidelity checks for clinical components, developing and disseminating materials and trainings, creating a robust suicide surveillance infrastructure, and by conducting an outcome evaluation to assess impact of the project on suicide attempts and deaths. In Year 4, the NYS Suicide Prevention Conference will be devoted to introducing health systems, county leadership, and providers across the state to Zero Suicide, to the NYS Suicide Safer Care Model, and to lessons learned from a county’s development of a Suicide Safer Care Network of Health Systems to create a local zero suicide safety net.

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.