Ending Suicide in Healthcare Settings: Time for Ohio to Lead. Mike Hogan Ph.D. Co-Chair, Zero Suicide Advisory Committee, Action Alliance

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1 Ending Suicide in Healthcare Settings: Time for Ohio to Lead Mike Hogan Ph.D. Co-Chair, Zero Suicide Advisory Committee, Action Alliance

Suicide and Self Harm are Big Problems 38,364 Suicides* 572,000 Hospitalizations** 752,000 Attempts Requiring Medical Attention** 1,100,000 Suicide Attempts** 8,700,000 Seriously Considered Suicide**

2 Suicide and Self Harm are Big Problems 38,364 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.

A National Response: Action Alliance Launch 9/10/2010 WE ENVISION A NATION FREE FROM THE TRAGIC EXPERIENCE OF SUICIDE PUBLIC-PRIVATE ALLIANCE Co-Chairs: Sen. Gordon Smith, Hon.

3 A National Response: Action Alliance Launch 9/10/2010 WE ENVISION A NATION FREE FROM THE TRAGIC EXPERIENCE OF SUICIDE PUBLIC-PRIVATE ALLIANCE Co-Chairs: Sen. Gordon Smith, Hon. John McHugh Updated National Strategy for Suicide Prevention Some current priorities: Zero Suicide in health care Changing the Conversation Research Agenda Impact Assessment SAVE 20,000 LIVES IN 5 YEARS

4 What is Zero Suicide in Healthcare? A priority of the Action Alliance and its Clinical Care TF Embedded in the National Strategy for Suicide Prevention Applying patient safety to mental health care A framework for systematic, clinical suicide prevention in behavioral health and healthcare systems Lessons learned in the past 15 years about suicidality and how to manage it A set of best practices and tools for health systems and providers, including: A fledgling movement and mission to keep people in our care alive and well which needs your leadership and support

5 What Is Zero Suicide? Part of the National Strategy for Suicide Prevention (2012 Update) ts/national-strategy-suicide-prevention/ GOAL 8: Promote suicide prevention as a core component of health care services, to include promoting "zero suicides" (8.1), continuity of care (8.4), coordinating services (8.7), and developing collaboration (8.8). GOAL 9: Promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors Suicide Care in Systems Framework August 2011

6 What is Different in Zero Suicide? We Need A Healthcare Focus on Suicide Prevention, and A Suicide Prevention Focus on Healthcare Until Now, We Have Neither Suicide Prevention Field Health Care An Urgent Burden in Crisis Care, ED s, Inpatient Psych But Not a Priority for Health Systems or Plans

7 What is Different in Zero Suicide? A Core Healthcare Focus on Suicide Prevention, and A Suicide Prevention Focus on Healthcare Health Care --All Behavioral Healthcare Settings Suicide Prevention --Integrated/Advanced Primary Care --ACO s, Integrated Systems --Health Plans

8 It is Time to Acknowledge: Suicide Deaths for People in Care is a Problem Half of the people who die by suicide saw a GP in previous month 70% among older men (where we know the risks are higher) South Carolina: 10% of all suicide deaths were people seen in ED in previous month People receiving care in public mental health system: Risk among people with depression and other mental health problems are 4-20x general population Ohio: Suicide was the second leading cause of premature community death in a mortality study of people in the public system

9 Ohio Study--Leading Causes of Death Cause ICD-9 Codes ICD-10 Codes M F N % Diseases of heart , 402, I00-09, I11, , I13, I20-51 Intentional self-harm (suicide) E X60-84, Y87.0 Accidents (unintentional injuries) E , V01-X59, E Y85-86 Malignant neoplasms (cancers) C00-C Symptoms, signs, & abnormal R clinical & laboratory findings, NEC Chronic lower respiratory diseases , 496 J40-J Diabetes mellitus 250 E Pneumonia & Influenza J Cerebrovascular diseases , I Assault (homicide) E X85-Y09, Y87.1

10 It is Time to Acknowledge: Suicide Deaths for People in Care is a Problem Half of the people who die by suicide saw a GP in previous month 70% among older men (where we know the risks are higher) South Carolina: 10% of all suicide deaths were people seen in ED in previous month People receiving care in public mental health system: Risk among people with depression and other mental health problems are 4-20x general population Ohio: Suicide was the second leading cause of premature community death in a mortality study of people in the public system Kentucky: 20% of all suicides in the state were among people who got any MH care (claims/deaths crosswalk) NYS: 226 reported suicides in public MH system in 2012 (15% of estimated 1500 suicide deaths in NYS)

11 What is Zero Suicide? A Focus on Patient Safety and Error Reduction James Reason s Swiss Cheese Model of accidents

12 Health Care is Not Suicide-Safe Continuity of Caring, or Refer and Hope Serious Injury or Death Take Concrete Steps for Safety, or No Action Treat Suicidality, or Send to Inpatient Care and Hope for the Best Suicidal Person Screen, Assess for Suicidality Or Don t Ask, Don t Tell

13 Systematic Suicide Care Plugs the Holes in Health Care Collaborative Safety Plan Put in Place, Followed Suicidal Person Screen, Assess for Suicidality Serious Injury or Death Avoided

14 Systematic Suicide Care Plugs the Holes in Health Care Collaborative Safety Plan Put in Place Suicidal Person Screen, Assess for Suicidality Treat Suicidality: Suicide-Informed CBT, Groups/classes on Inpatient, DBT, CAMS Serious Injury or Death Avoided

Calls after ED, Inpatient Collaborative Safety Plan Put in Place Treat Suicidality:

15 Systematic Suicide Care Plugs the Holes in Health Care Systematic Suicide Care Suicidal Person Serious Injury or Death Avoided Continuity of Caring: Follow-up Calls after ED, Inpatient Collaborative Safety Plan Put in Place Treat Suicidality: Suicide-Informed CBT, Groups/classes on Inpatient, DBT, CAMS Screen, Assess for Suicidality

16 What is Different in Zero Suicide? Suicide Prevention as a core Health Care responsibility A systematic clinical approach in health systems, not the heroic efforts of crisis staff and individual clinicians. Systemic approaches have worked to prevent suicide: USAF UK (While et al., 2009)

17 What Is Zero Suicide? A Systematic Approach to a Boundaried Population A Systematic Approach. U.S. Air Force Systems approach stressing social connectedness Would a systematic approach work in health care?

18 What Is Zero Suicide? A Systematic Approach in Health Care Systematic Suicide Prevention in Health Care Henry Ford Health System o First systematic approach in health care

20 Henry Ford Health System 120 Launch: Perfect Depression Care Suicide Deaths/100k HMO Members

21 What Is Zero Suicide? A Systematic Approach in Health Care Systematic Suicide Prevention in Health Care: Innovators Henry Ford Health System o First systematic approach in health care Magellan Maricopa Collaborative: Phoenix o Adapting systematic approach in specialty behavioral health Veteran s Administration And in Zero Suicide innovation sites in multiple states o Community mental health (e.g. Centerstone) o Advanced/integrated primary care (e.g. Institute for Family Health) Supported by Suicide Prevention Resource Center (SPRC) o Learning Community (contact Julie Goldstein Ph.D: jgoldstein@edc.org) o Website up, in development v.2.0: (

22 What is Zero Suicide? Suicide Prevention as a core Health Care responsibility A systematic clinical approach in health systems, not the heroic efforts of crisis staff and individual clinicians. Applying new knowledge about suicidality, and about directly treating it From it was inevitable or it was your fault toward a more nuanced understanding : ambivalence, resilience, and recovery From risk assessment and containment to an emphasis on collaborative approaches to safety, treatment, recovery From token support for some survivors, to support for loss and attempt survivors, and learning with them

23 Task Force Report Suicide Care in Systems Framework Thinking Differently About Suicidality

24 What is Zero Suicide? Suicide Prevention as a core Health Care responsibility A systematic clinical approach in health systems, not the heroic efforts of crisis staff and individual clinicians. We have new knowledge about suicidality Approaching suicidality as a comorbidity, and using new knowledge to detect risk, keep people safe, and treat the risks. What s new: Evidence Based and Best Practices: Reliable screening and assessment approaches Interventions and tools for safety, means restriction Effective treatments for suicidality as well as mental illness Understanding and managing engagement and follow-through Embedding these approaches in EMR s, clinical workflow

25 Zero Suicide/Suicide Safer Care: The Essential Elements and Steps 1. Leadership commitment to a safe and just culture, and a commitment to reduce deaths among people under care and collaboration with survivors 2. Systematic identification and assessment of suicide risk, with care pathways that assure timely and appropriate care 3. A competent, confident, caring workforce 4. Effective and evidence based care including collaborative safety planning and lethal means restriction and effective treatment of suicidality 5. Continuing contact especially during periods of elevated risk e.g. after acute care 6. Data driven quality improvement and measurement

26 Suicide Prevention Resource Center (SPRC) Supports Best Practices and Tools for ZeroSuicide A website with tools and tips becoming available on-line, NOW: V 2.0 will include on-line tools e.g. screening, pathways Access to free, high quality distance learning modules (C-SSRS, Safety Planning, Acute Care Follow-Up) Access to workforce (readiness) survey Access to organizational survey on suicide safer care One source for training of staff (others exist) Sponsor of ZeroSuicide Academy Learning Community of Innovators in ZeroSuicide

27 What Is Zero Suicide? A fledgling movement and mission There are those who say that the human body is much more complicated than our airplanes. There are those that counsel patience and say that these patient safety issues are complicated and they simply take time to fix. But I take a different approach. I wish we were less patient. Every day, when each of us goes to work we are choosing individually and collectively how many lives are going to be lost And the harm is so great, the numbers are so huge, that I don t think we should wait 20 more years until there are 4 million more preventable medical deaths. We should change the way we do business now. It s not going to be easy, but it is possible. Chesley Sully Sullenberger Healthcare Financial Management, 2013

28 Zero Suicide Summarized Suicide among people in our care is a problem. These are preventable deaths We needed and now have the tools for systematic approaches: Evidence that (only) systematic approaches work Tools are now available: o Reliable screens o Safety planning interventions o Effective treatment/management approaches o Care pathways and EMR supports o Implementation assistance: website, learning community Anything less would be uncivilized

29 Thank You

The Emerging Zero Suicide Paradigm Reducing Suicide for Those in Care. Julie Goldstein Grumet, PhD Mike Hogan, PhD August 28, 2014

The Emerging Zero Suicide Paradigm Reducing Suicide for Those in Care Julie Goldstein Grumet, PhD Mike Hogan, PhD August 28, 2014 Moderator and Presenters Sarah A. Bernes, MPH, MSW Research Associate,