Background: Pyramid of Suicidal Behaviors--U.S.

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1 Ending Suicide in Healthcare Settings: How many deaths are acceptable? What are our next steps to save lives? Update and Recommendations for Commissioners Michael Hogan, Ph.D.

2 Background: Pyramid of Suicidal Behaviors--U.S. 35,839 Suicides* 572,000 Hospitalizations** 752,000 Attempts Requiring Medical Attention** 1,100,000 Suicide Attempts** 8,700,000 Seriously Considered Suicide** Source: * National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2009). Web-based Injury Statistics Query and Reporting System (WISQARS). Available from: **Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

3 Action Alliance Launch 9/10/2010

4 Variability: Age-Adjusted Suicide Rates by State -- United States, 2006 (U.S. Avg ) Wash., D.C. State (Lowest & Highest) New Jersey 6.7 Alaska 22.1 Age-adjusted Rate (per 100k) Rates per 100,000 population 0.0 to to to to Source: Centers for Disease Control and Prevention (CDC) vital statistics

5 More Variability: Suicide Rates by Age, Race, and Gender United States, 2007 Source: National Center for Health Statistics Note: Non-Hispanic Ethnicity

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7 Clinical Care & Intervention Task Force: Report and Recommendations

8 Who Needs Our Help NOW?

9 Impact of a Systems Approach: Intervening With a Population Under Care WE LEARNED FROM THREE SYSTEMS U.S. Air Force Henry Ford Health Systems Magellan Maricopa Collaborative And ONE NETWORK National Suicide Prevention Lifeline

10 Lessons Learned Since the NSSP A Shift in Perspective From: Training and tools Individual provider actions; suicide care as individual specialty Episodes of crisis Treat the mental illness, contain the suicidality To: Systems & culture change Suicide prevention woven into all aspects of care; part of everyone s job Continuity of care Treat mental illness and suicidality

11 Impact of a Systems Approach: U.S. Air Force Program Number of suicides Suicide rate Year 0.0 Number of Suicides per Year Rate per 100,000 3 per. Mov. Avg. (Number of Suicides per Year) Source: Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force: cohort study. British Medical Journal, December 13, 2003.

12 Making Saving Lives a Priority in Systems of Care Systems where we can work on saving lives: Healthcare or behavioral health systems Networks of providers Military branches, college campuses Our systems of care are: Responsible for a defined population Have shared leadership, policy, and influence over programs and subunits Have a mission of care, treatment, support

13 Mental Health Care is a Bridge to Recovery: Is Our Bridge Safe?

14 Systems Approach: Example Magellan Maricopa Collaborative Steering committee with formal guiding charter BH Workforce Surveys Attitudes, knowledge, skills, supports Instituted all-staff training (2,400 ASIST trained) Suicide Attempt Survivor Support Groups & Family Engagement Standardized screening, assessment, stratification and regimen of key interventions

15 77.2 Impact of a Systems Approach in Behavioral Health Magellan Maricopa County Population in Care Deaths/100T (People in BH Care) 54% FY2007 FY2008 FY2009 FY2010 FY2011 FY2012

16 Impact of a Systems Approach Magellan Active Episodes - SMI Only % FY2007 FY2008 FY2009 FY2010 FY2011 FY2012

17 Saving Lives Saves Money: Case Examples

18 Henry Ford Health System Systems Approach: Example Perfect Depression Care and zero suicide Systematic clinical changes: Planned care model o Screening and risk stratification (3 level)s with pathways to care and associated interventions; emphasis on means restriction o Established and maintained clinician competency in Cognitive Behavioral Therapy (CBT) Filling the cracks: Access to immediate care o Drop-in group medication appointments o Advanced same-day access to care o visits

19 Henry Ford Health System Redefining What Can Be Done I: U.S. Air Force Program

20 Systems Approach: International Support Implementation of 9 mental health service recommendations in England and Wales and suicide rates, : a crosssectional and before-and-after observational study. While et al (February 2, 2012) 1. Inpatient psych unit safety 2. Assertive outreach team 3. 24/7 crisis team 4. 7 day follow-up 5. Written policy on non-adherence 6. Dual diagnosis treatment 7. Criminal justice sharing 8. Debriefing and family contact after suicide 9. Front-line clinical staff trained in management of suicide risk at least every 3 years

21 Systems Approach: International Support Services that had implemented seven to nine recommendations had a significantly lower suicide rate than those implementing fewer Powerful impact of a comprehensive approach p<.005 Suicide death rate 17% lower under comprehensive approaches (in U.S. equates to 6,000 lives/year) Some recommendations have high impact: having a 24 hour crisis team, having a dual diagnosis policy, and post suicide multidisciplinary review

22 What Can SMHA s Do, And What Help Is Available? Use Leadership and Leverage: Seek Innovators who will Implement a Systems Approach and Commit to Working Toward Zero Suicide for Their Members Key Elements: Leadership Commitment to Goal, to a Culture of Safety and to Continuous Improvement Staff Awareness (Training) on Suicidality (e.g. ASIST) Screening/Risk Stratification and Pathways to Indicated Care o Screening Example: Columbia Suicide Severity Rating Scale Address Suicidality, not Just Mental Illness o Examples: EBP s (CBT, DBT), Safety Planning Follow-Up After Attempts, ED visits, Hospitalization o Example: Lifelines Follow-Up Red = Training Modules in Development by NY OMH/Columbia

23 Action Alliance: Next Steps --NSSP Update: Expected Release on World Suicide Prevention Day (Sept 12, 2012) --Focus on a short list of top priorities to include zero suicide adoption and follow-up after acute care --Dialogue with CMS continues about baking SP actions into health care reform

24 THANK YOU!