Saving Lives & Money:

Transcription

1 JOHN DRAPER, Ph.D., Lifeline Project Director & SHARI SINWELSKI, MS, EdS, LPCC, Lifeline Assoc. Project Director Saving Lives & Money: Delivering the Best Care for Suicide Prevention Lessons from Lifeline Crisis Centers Speaker Name Title Organization

2 Saving Lives & Money: Delivering the Best Care for Suicide Prevention Lessons from Lifeline Crisis Centers John Draper, Ph.D. Lifeline Project Director & Shari Sinwelski, MS, EdS, LPCC Lifeline Associate Project Director NatCon, March 2016

3 How can we prevent more suicides?

4 Suicide Prevention Approaches: What Works? Reduction in access to lethal means Access to care and prompt outreach for persons in crisis Assessment/Identification Care that is collaborative/person-centered, teaches skills, and suicide-focused Follow-up/continuing care

5 Care Systems Are Missing Suicidal Persons In the year they died by suicide: 32% saw a mental health professional 20% within the past month (Luoma et al, 2002) 39% visited an emergency room 10% within the last 2 months (Gairin et al, 2003) 77% saw a PCP 45% within the last month (Luoma et al, 2002)

6 Treatment as Usual not enough to prevent suicide Risk of suicide for comparable groups not receiving psychiatric treatment, past year: Psychiatric medication alone: 6x more risk Outpatient Only: 8x more risk ED patient discharged: 28x more risk Inpatient: 44% more risk Hjorthoj, CR, Madsen, T., Agerbo, E. & Nordentoft, M., 2014

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8 How do we help persons who are feeling suicidal? Assess & Treat (yes) Engage, Support and Empower (YES!!!)

9 Are High Risk People Getting Care? WHO Study (Bruffaerts et al, 2011) Surveyed 55,302 persons with suicidal thoughts or behaviors from 21 countries 45-51% attempt survivors did not seek care within a year after the attempt Why Not? 58% said low perceived need for care 40% wish to handle the problem alone 15% structural barriers (financial, distance) 7% stigma

10 How can our system engage more people at high risk of suicide? Policy makers must decide whether to use marketing principles (and scarce resources) to attract suicidal people to existing services, or invest in culturally appropriate interventions in more acceptable settings. Bruffaerts et al s findings suggest the latter may be a more promising way of meeting suicide prevention targets. A. Pitman & D.P.J. Osborn, BJP, 2011

11 Engaging High Risk Persons by Telephone: Does it Work? Care Linkages Gould, Munfakh, Kleinman & Lake, 2012: 376 suicide callers from 16 Lifeline centers 57% had made past attempts, 37% had a plan and 7% were attempting at the time of their call to center Evaluator follow-up calls found about 44% had linked to care Over half that did not connect identified main reason: the problem was not severe enough and/or could be handled without treatment but they were calling the Lifeline!

12 Engaging High Risk Persons by Telephone: Does it Work? After Discharge from Emergency Department Vaiva et al, 2006: 605 attempt survivors, discharged from 13 EDs in France Assigned to telephone contact (support, empathy, suggestion, crisis intervention, review aftercare plan, etc.) or Treatment as Usual (clinic referrals) More (75%) agreed to telephone intervention than past suicide prevention therapy referrals (51%, Guthrie et al, 2001) Significant reductions in reattempts for persons contacted by phone within a month of discharge Telephone contact detected high risk persons for timely emergency care referrals

13 Immediate Access Can Save Lives Many a suicide might be averted if the person contemplating it could find the proper assistance when such a crisis impends. Clifford Beers, 1908, A Mind That Found Itself Founder of America s Mental Hygiene (Reform) Movement

14 Hotlines: Do They Reduce Distress and Suicidality Gould, Kalafat & Munfakh, 2007: Crisis callers: significant reductions in confusion, anger, anxiety, helplessness & hopelessness at end of call, more so at 3 week follow-up Suicidal callers: significant reductions in suicidality, psych. pain and hopelessness at end of call and at 3 week follow-up Nearly 12% of suicidal callers spontaneous report: call prevented him/her from killing or harming self

15 I am less likely to feel that a call to 911 saved my life as much as, say, just being listened to. From 2007 Lifeline Focus Group Of Suicide Attempt Survivors

16 Care Systems: Immediate Access Saves Lives Mental Health Services that Reduced Suicides, England and Wales ( ) D. While, et al, 2012 Examined impact of implementing 9 key mental health service recommendations to reduce suicide across National Health Service regions Of the 9 recommendations studied, a 24 hour crisis team had the greatest relationship with the reduction in suicides. The study defined 24 hour crisis teams as "community services that include a single point of access for people in crisis available 24 hours a day. Similarly, implementation of an assertive outreach policy was associated with a significant decrease in the suicide rate of those who were non compliant with medication or missed their last appointment.

17 Crisis Centers: Innovators in New Technologies to Promote Access to Care

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19 Lifeline Mission To effectively reach and serve all persons who could be at risk of suicide in the United States through a national network of crisis call centers.

20 About the Lifeline SAMHSA-funded Administered by Link2Health Solutions, an independent subsidiary of the Mental Health Association of NYC Project partners: NASMHPD, National Council of Behavioral Health, Columbia University and the Department of Veterans Affairs Comprised of 165 crisis centers (and counting) in 49 states

21 JULY 2007: VA & SAMHSA launch first national suicide hotline for Vets Calls routed through TALK (press 1 for vets & active military service) 24-7 access to trained counselors at VA Lifeline Centers back-up service to ensure all calls are answered

22 The National Public Safety Net: Lifeline Crisis Centers

23 Lifeline s Network of Collaborators SAMHSA VA Consumer- Survivor Subcommittee Lifeline Steering Committee Network Centers Standards, Training & Practices Subcommittee

24 Lifeline Evaluation and QI Process IDENTIFY BEST PRACTICES EVALUATION STANDARDS, GUIDELINES & POLICIES TRAINING & T.A. IMPLEMENT

25 WHAT WORKS: Crisis Hotline Evaluations Mishara et al: Helper behaviors related to positive outcomes (2007): -- Empathy & respect -- Supportive approach and good contact (moral support, validation of emotions, engaged, offers call back, reframing, self-disclosure) -- Collaborative problem solving (reformulation, reflection of feelings, empowers to plan & act on resources, etc.) -- Not active listening alone

26 Lifeline Best Practices for Helping Persons At-Risk of Suicide FINDINGS: Crisis hotlines are an effective service for suicidal callers BUT: Some suicidal callers are missed Some callers are suicidal at follow up Low follow through on referrals Callers at imminent risk may be missed Callers at imminent risk may not be rescued Marked variability among centers in addressing suicide; variability related to amount of suicide training Follow-up information on barriers can improve training and clinical services Kalafat et al. (2007); Gould et al. (2007); Mishara et al. (2007a, 2007b)

27 Lifeline Best Practices for Helping Callers Distributed to the network early 2014 All Lifeline callers will receive effective, high quality service from Lifeline helpers Provide good contact with callers Improve collaborative problem solving with callers Improve assessment of suicide risk with callers Improve helper practices in assisting callers at imminent risk Lifeline and its centers will improve the continuity of care for individuals in crisis to enhance their safety and stability Improve caller linkages to care/support services Enhance gap-filling supports for individuals at risk

28 Lifeline Risk Assessment Standards DESIRE for suicide INTENT to die CAPABILITY of suicide BUFFERS or reasons for living (Joiner et al, 2007)

29 Assessment Standards Recommended National Action Alliance for Suicide Prevention Clinical Care & Intervention Task Force, 2011: Lifeline Four Core Principles of Risk Assessment recommended framework for all crisis, emergency and behavioral health clinicians

30 IMMINENT RISK POLICY (2011) BASIC TENETS OF POLICY Active Engagement/Least Invasive Active Rescue Collaboration (with emergency service entities)

31 The best way to keep individuals safe from suicide is to empower them to want to keep themselves safe

32 Impact of Lifeline IR Policy on Center Practices Gould, Lake, Munfakh, Galfavy, Kleinman, Williams, Glass & McKeon, 2015 (in press) Data: 491 callers classified at imminent risk by 132 counselors from 8 Lifeline centers 76% collaborated with counselor to address and reduce risk Of those, over half collaborated in safety planning, reducing access to lethal means, etc. Over 1/3 consented to follow-up support 40% risk was reduced by the end of the call so rescue (911) was not needed

33 What callers at Imminent Risk Cannot Be De-Escalated ( Active Rescue)? Gould et al, in press: Types of callers rated by counselors to be at imminent risk where risk could not be reduced by end of call were most likely to: Have high levels of reasons for dying (Desire) Be attempting suicide on the call (Intent) Be intoxicated (Capability) These callers were notably more difficult to engage.

34 Crisis Centers: Essential Links in Chain of Care for Public Health and Safety Law Enforcement 40% (53) Formal Relationship (MOU, etc.) Mobile Crisis Teams 31% (42) Formal Relationships (MOUs, contracts, etc.) 30% (40) Provide Mobile Outreach Services 911 Centers 22% (30) Formal Relationships (MOU, etc.) Emergency Departments 38% (30) Formal Relationships (MOU, etc.)

35 Crisis Centers: Diversion Cost-Efficiencies Georgia Crisis & Access Line: Single entry point for behavioral health system. Triage, linkages to clinics, hospitals and mobile outreach 50% decrease in outpatient appointment wait time Saved $16m in unnecessary state hospital admissions in <5 years, one county alone BHR in Mo: Youth Connection Helpline diverted 98% of youth in crisis from emergency/input services, with 80% of youth getting linked to community based face-to-face services within 24 hours

36 Lifeline ASIST Trainings Independent Lifeline workgroup determined ASIST best fit for crisis centers (2006 ASIST adapted for crisis centers (2006) 112 (68%) centers have participated in the T4T 265 individuals have completed a Lifeline hosted ASIST T4T 630 workshops completed since 2007 At least 6,600 individuals have been trained

37 Summary of ASIST-Lifeline Results Gould, Cross, Pisani, Munfakh & Kleinman, SLTB, Lifeline centers, 1507 monitored calls, 1,410 suicidal individuals. Counselors trained in ASIST: by the end of call, caller felt Less depressed Less overwhelmed Less suicidal More hopeful ASIST elements most related to positive outcomes: Exploring reasons for living/dying (active engagement) Review of informal support contacts (who cares about them?)

38 Summary of ASIST-Lifeline Results Gould, Cross, Pisani, Munfakh & Kleinman, SLTB, Lifeline centers, 1507 monitored calls, 1,410 suicidal individuals. Counselors trained in ASIST: by the end of call, caller felt Less depressed Less overwhelmed Less suicidal More hopeful ASIST elements most related to positive outcomes: Exploring reasons for living/dying (active engagement) Review of informal support contacts (who cares about them?)

39 Number of Centers Most Centers Provide Follow up Services Yes Follow up Services No

40 Does follow-up with at-risk individuals reduce suicide risk? Interviews with 550 suicidal hotline callers who received follow-up calls from a Lifeline crisis center; Gould et al, 2014 Approximately 80% of interviewed callers perceived the follow-up intervention as having stopped them from killing themselves either a little or a lot. Why were they helpful? It reminded me of my choice. Over the couple of days after I called the center, I was still considering the idea of killing myself, and the calls really reinforced that I had chosen not to. The follow up calls really gave me the message that they really did care, and that it wasn't just a one time resource if I needed to turn to them again. That was really what kept me from continuing with my [suicidal] thoughts.

41 Crisis Center Life and Cost Savings: Post-Discharge follow-up, ED & Inpatient High rates of suicides and return visits post-discharge from EDs, inpatient units Lifeline crisis center models for post-discharge follow-up being funded and evaluated by SAMHSA SAMHSA-Truven Health Analytics, Follow-up ROI: ED: ROI of $1.70 for commercial, $2.00 for Medicaid Hospital: ROI of $1.76 commercial, $2.40 Medicaid Health follow-up, : 93% suicidal persons linked to care post-discharge 92% no readmissions; no reattempts Currently being evaluated by Gould team

42 Rand Study, 2016 In a 2014 evaluation of 10 California crisis centers: Callers to Lifeline-member crisis centers were more likely to be assessed for suicidality and show reductions in distress by the end of the call. R. Ramchand, et al, in press

43 Potential Cost and Burden Reductions of Crisis Centers Emergency Departments reduce unnecessary visits, assist with linkages, etc. Inpatient units reduce unnecessary admissions, aftercare follow-up, etc. Outpatient clinics appropriate linkages, between appts & after-hours support, link to mobile outreach, etc. Law Enforcement reduce unnecessary encounters with law enforcement, etc.

44 Network Resource Center

45 Lifeline Members Appreciate All centers note membership is valuable, and over 2/3 rate it as extremely valuable. What do they rate as Extremely Valuable? Access to Best Practices (54%) Data & Reports (48%) Availability of Resources on NRC (40%) Credibility with Funders (38%) Part/full payment of Accreditation Expense (30%) Annual Stipend (30%) Support/Advocacy Letters (25%) National Evaluations (22%) Attempt Survivor Resources (21%)

46 Summary Use of communications technologies can effectively: engage persons at high risk and reduce distress & suicidality Can promote cost-efficiencies What works: good contact; collaboration reasons for living/dying connecting to supports; sustaining connection (follow-up) Assessment and interventions applicable to all practitioners in the field Lifeline Resources Risk Assessment Standards Imminent Risk Policy NRC

47 Thank you! John Draper Project Director Shari Sinwelski Assoc. Project Director Suicidepreventionlifeline.org