Attachment 10 - 116A-12 MANAGEMENT OF PATIENTS AT RISK FOR SUICIDE.pdf

1. PURPOSE: To outline the policy and provide guidance for the assessment and management of patients at risk of suicide.

2. POLICY: It is the policy of the VAMC-Memphis to identify individuals at risk for suicide while under the care of and following discharge from this health care facility. These policies and procedures will address the following: implementation of strategies to identify patients at risk for suicide and the proper assessment, treatment, and management of suicidal patients; processes for evaluation and consultation by mental health staff, appropriate and timely communication from other services to Mental Health Service (MHS), and timely reciprocal communication from MHS to other services; use of suicidal precautions and one-to-one observation; documentation of relevant information in CPRS; and staff training.

3. RESPONSIBILITY: This policy applies to the VA Medical Center at Memphis and the North and South Community Based Outpatient Clinics (CBOCs).

a. The Medical Center Director or Designee is responsible for assuring compliance with this policy. The Medical Center Director is responsible for providing the VISN 9 Network Office (including Network Director, Chief Medical Officer, and Mental Health Services Manager) with copies of all locally developed suicide prevention policies and procedures. Changes to any policies or procedures involving the management of at-risk or suicidal patients must be directly communicated to the Network Office.

b. Service Chiefs or Designees are responsible for ensuring that providers accurately comply with this policy.

c. All Providers are responsible for assuring that all patients presenting with behavioral health issues are assessed for suicide risk as established in this policy. All non-Mental Health (MH) Providers are responsible for consulting MH in the management of all patients at risk for suicide.

Emergency Room (ER) Providers must involve MH staff present in the ER or on-call for the ER in the assessment of all patients with behavioral health issues. (ER) MH providers will complete a risk assessment and safety plan on all referred mental health patients that check into the ER.

The safety plan will be reviewed with the patient, significant other or family member(s) and a copy will be provided to the patient. Providers will also ensure the following five elements are included and assessment and documented:

1. Determine urgency of need for care

2. Identify the appropriate setting for subsequent evaluations and treatment

3. Arrange for treatment as appropriate

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 116A-12

Dated: February 26, 2018

Expires: February 25, 2021

Title: MANAGEMENT OF PATIENTS AT RISK FOR SUICIDE

36C24920R0114 - Attachment 10

4. Provide Veterans with the name and contact information for a mental health professional that they can contact, even before they begin treatment, if they have questions or concerns as well as provide instructions about accessing emergency services; and

5. Respond to the patient’s questions or concerns and facilitate engagement in care.

a. If the designated provider and/or mental health profession is added as a co-signer on a negative screening initiated by an RN. The provider will acknowledge and co-sign the note no later than the next business day.

b. When the provider co-signs the note at this time, they will ensure that appropriate treatment appointments are in place for the full evaluation to occur within 30 days of request, thereby completing the remaining required elements.

d. Registered Nurses (RNs) are responsible for assuring that all patients presenting with behavioral health issues have a completed initial screening evaluation for new patients in collaboration with a designated provider that includes but is not limited to MDs, Dos, NPs, Pas, CNS as well as Clinical Pharmacy Specialists and Mental Health Professions. The RN will ensure the following while the designated provider maintains the responsibility for full completion of the screening evaluation process:

1. Determine urgency of need for care

2. Provide Veterans with the name and contact information for a mental health professional that they can contact, even before they begin treatment, if they have questions or concerns as well as provide instructions about accessing emergency services; and

3. Respond to the patient’s questions or concerns and facilitate engagement in care

4. When the RN is completing the initial screening evaluation, and the result is positive, s/he will take appropriate nursing actions which follow policy and procedures to ensure the patient is safe. The RN will also immediately collaborate with the corresponding provider to communicate the positive risk assessment findings using the Situation, Background, Assessment and Recommendation (SBAR) handoff report.

5. When the initial screening evaluation is negative, the RN will document the findings, but immediate provider involvement is left to the judgement of the RN. For continuity of care, the designated provider should be added as a co-signer to the negative initial screening evaluation.

e. Mental Health Program Staff: All staff working in Mental Health program need to have the National Suicide Prevention Greeting on their voicemail (refer to attachment E). As part of a Patient Safety Alert, all MH staff across the system will make sure their outgoing voice mail messages include the language in Attachment E. This applies to VA desk phones. Voice over Internet Protocol (VolP), and VA cell phones (whether blackberry or other devices issued by VA).

Mental Health staff members’ personal cell phone numbers are not to be given out to patients receiving mental health care. Patients must only be given appropriate VA contact phone numbers with the required voice mail content.

f. The Suicide Prevention Coordinator (SPC) or Designee is responsible for overseeing the overall suicide prevention efforts at the VA Medical Center Memphis and establishing and monitoring Patient Record Flags (PRF) for patients identified as being at risk for suicide. The SPC is responsible for coordinating the training of all staff on suicide prevention.

g. VA Police are responsible for assisting Mental Health Service clinicians in bridging communications between the VA Medical Center Memphis and community law enforcement officials to obtain health and welfare checks. The VA Police are also responsible for obtaining information from public law enforcement officials and communicating back to the Suicide Prevention Coordination and/or MHS clinician(s) the results of their efforts the same day they obtain information on welfare checks.

4. PROCEDURE:

a. Face-to-Face Patient Evaluation:

(1) Patients who, during a face-to-face evaluation at the VAMC Memphis or any of the CBOCs (North, Nonconnah, South, Bolívar TN, Dyersburg TN, Jackson TN, Savannah TN, Byhalia MS, Smithville MS, Tupelo, MS, Tremont, MS, Houlka, MS, Helena AR, and Jonesboro AR), are identified as at imminent or high risk for suicidal behavior (Attachment A: Non Mental Health Suicide Prevention Assessment) will be referred to a mental health provider for an immediate detailed suicide assessment and initiation of a plan of care. Patients identified as moderate or low risk for suicide will be referred to a mental health provider (see Attachment A).

If at any time a non mental health provider has concerns regarding a patient's suicide risk level, the provider can request an immediate consultation by a mental health provider. MH providers will complete a risk assessment and safety plan on all referred mental health patients. The safety plan will be reviewed with the patient, significant other or family member(s) and a copy will be provided to the patient.

(2) Whether transferring a telephone call from a suicidal patient, or the suicidal patient is physically presenting for care, all staff members are to use a "warm handoff." This requires a direct, in-person handoff of patients between staff as well as appropriate handoff communication (e.g., level of suicidal or homicidal risk, specific care instructions, etc.) given verbally to the receiving provider and documented in CPRS. All patients deemed to be at imminent or high suicidal risk must be attended by a staff person (one-to-one observation) at all times (including when using restroom) until given clearance to discontinue this level of care by a mental health clinician.

(3) Once patients are identified as imminent or high risk for suicide, a mental health provider will conduct a detailed suicide assessment (see Attachment B) and document relevant factors in the medical record (see Section C below). The safety plan will be reviewed with the patient, significant other or family member(s) and a copy will be provided to the patient.

(4) In the event that a veteran at imminent or high risk for suicide elopes from staff while under observation, staff will immediately contact the VA Police and will document the elopement in CPRS. VA Police will follow-up with Suicide Prevention Coordination and/or requesting provider on disposition. The VA Police will follow their own standard operating procedures for patient elopement. Elopement of imminent or high risk for suicide patients will qualify under VA Medical Center at Memphis Missing Patients Policy (0083).

b. Telehealth Contacts:

(1) Patients who, during a Telehealth evaluation at the VAMC Memphis, any of the CBOCs (North, Nonconnah, Bolívar TN, Dyersburg TN, Jackson TN, Savannah TN, Tupelo, MS, Helena AR, and Jonesboro AR), or at their home, are identified as at imminent or high risk for suicidal behavior (Attachment A: Non Mental Health Suicide Prevention Assessment) will be referred to the Suicide Prevention Team and/or the VAMC Memphis Emergency Department Social Worker for an immediate detailed suicide assessment and initiation of a plan of care. Patients identified as moderate or low risk for suicide will be referred to a mental health provider (see Attachment A). If at any time a non-mental health provider has concerns regarding a patient's suicide risk level, the provider can request an immediate consultation by a mental health provider. MH providers will complete a risk assessment and safety plan on all referred mental health patients.

The safety plan will be reviewed with the patient, significant other or family member(s) and a copy will be provided to the patient.

(2) All Telehealth Providers will be trained by 3/1/18 in the established protocol for management of Veterans presenting with imminent or high-risk for suicide.

c. Telephone Contacts:

(1) A person who calls the VAMC Memphis, the North CBOC or the South CBOC and expresses suicidal concerns will be referred to MH clinical staff for immediate consultation. In order to make the referral to MH clinical staff with efficiency and care the recipient of the call will follow the steps in the guide for responding to suicidal callers (see Attachment C). The guide is to be used by any non MH staff member receiving a call from a person at risk for suicide. The guide outlines the "33" telephone priority access to the VAMC telephone operators who will then activate the MH emergency "555" paging system.

(2) In the event that a suicidal call is lost or dropped, the VA staff member(s) involved in the call will contact the VA Police for assistance.

(3) After the mental health professionals assessment has been completed and it has been determined that the caller is not presenting an imminent or high risk, the mental health provider will provide the caller with additional information about what to do in the event of a crisis such as calling: 911; the local Suicide Prevention Coordinator (SPC); and/or the National Suicide Prevention Hotline number (1-800-273-8255), http://www1.va.gov/health, where the caller can be connected with local or regional resources. The mental health provider will make the SPC a co-signer to the note and the SPC will assure appropriate follow-up. All appropriately identified medical center staff will have access to these telephone numbers and will be trained in the appropriate suicide prevention procedures for the VA Medical Center Memphis and the North and South CBOCs. Procedures for calls that occur during both administrative and non-administrative hours have been established and communicated to all staff.

(4) If a veteran is identified as at-risk for suicide through an incoming telephone call, but is unwilling to come in for a face-to-face evaluation, the Suicide Prevention Coordinator and/or other involved mental health professionals will inform VA Police. VA Police will assist in obtaining a health and welfare check through local community law enforcement.

(5) If a veteran known to be at-risk for suicide is a "no-show" for a scheduled mental health appointment, MH staff will make an immediate attempt to contact the veteran by telephone ensure his/her safety and offer a MH follow-up appointment. If the MH clinician is unable to reach the veteran and assesses that the suicide risk is high, then the clinician will immediately contact the VA Police to request a health and welfare check through local community law enforcement. Attempts to reach at-risk veterans should be documented in CPRS and should continue until the veteran is physically located and assessed.

(6) When VA Police are engaged to assist in the management of an at-risk patient, the VA Police will provide written and/or oral communication to the Suicide Prevention Coordinator and/or MH clinician regarding the results of their intervention. The SPC and/or MH clinician will enter a summary of the police intervention in CPRS to assist in the plan of care for veterans.

http://www1.va.gov/health http://www1.va.gov/health

d. Documentation: Any at-risk suicidal behavior will be documented in the medical record, and the SPC will be identified as an additional signer with alerts in CPRS. Documentation of detailed suicide assessments by MH providers should include, at a minimum, the following:

(1) Patient's current presentation, individual strengths and weaknesses, history, and psychosocial stressors;

(2) Specific factors that may increase and factors that may decrease the risk for suicide;

(3) Presence of psychiatric illness, including specific psychiatric symptoms such as hopelessness, anxiety, agitation or intense suicidal ideation;

(4) Current alcohol or substance use;

(5) Accessibility to methods for self-harm and intent to use same;

(6) Initial recommendations for care, including choice of treatment setting;

(7) Patient's immediate response to staff intervention; and

(8) Appropriate telephone number(s) for administrative and non-administrative hours will be provided in writing to at-risk patients and/or significant others (including National Veterans hotline number 1-800-273TALK); and

(9) CPRS co-signatures of all staff involved in warm handoffs and other relevant clinical staff (e.g., SPC). The note in CPRS should contain the name and discipline of the staff who is receiving the patient. For example: "I delivered the patient to Nurse Nancy, RN, in the Emergency room, and discussed the case with her."

e. Initial Clinical Management: Initial therapeutic interventions should be instituted for patients with suicidal thoughts, plans, or behaviors and include the following:

(1) Immediately attending to patient safety. Specifically, all patients deemed to be at imminent or high risk for suicide must be attended by a staff person (one-to-one observation) until given clearance to discontinue this level of care by a mental health clinician. Clinicians should ensure that patients do not have access to implements or objects that might facilitate harm to self or others or be in a physical location that would increase the likelihood of self-injurious behavior.

(2) Determining the least restrictive setting for treatment while maintaining patient safety and an efficacious treatment approach. If necessary for patient safety, involuntary holds or commitments may be initiated following state and local laws and statutes as required.

(3) Establishing a cooperative and collaborative clinician-patient relationship. Clinicians working with suicidal patients will encourage compliance with treatment to improve functioning and reduce immediate risk.

(4) Providing education to patients, family, significant others, and friends when indicated.

This education includes providing VA telephone numbers and suicide hotline numbers.

f. Ongoing Interventions and Treatment: Veterans may benefit from different treatment settings such as involuntary inpatient hospitalization, residential treatment, intensive outpatient programs, and ambulatory care clinics. Choice of treatment setting depends on many factors including the severity and acuteness of suicidal ideation. Risks to patient safety must be the primary consideration. The benefits of intensive interventions (e.g., hospitalization) also must be weighed against their possible negative effects, such as loss of autonomy, disruption of employment, financial and other psychosocial stress, and social stigma. Variables that influence the intensity of interventions include, but are not limited to:

(1) Assessment of patient's current suicide risk and/or potential danger to others;

(2) Medical and psychiatric co-morbidity;

(3) Availability of a psychosocial support network outside the treatment setting, and

(4) Ability of patients to provide adequate self-care, to give reliable self-report, and to cooperate with treatment.

(5) Safety plan completed on all high risk patients before discharge from the Psychiatric inpatient ward, SARRTP and PTSD residential programs. Safety plan will be completed with patient and a copy will be provided to the patient. If significant other and/or family member(s) are available, the safety plan will be reviewed with them (see Attachment D).

g. Treatment Planning: The initial treatment plan should document the steps taken towards ensuring patient safety, patients' level of cooperation with these procedures, and steps taken towards addressing the factors that created the acute distress.

(1) Clinicians with responsibility for treating patients following an inpatient admission must have timely access to patients' discharge summaries in CPRS. If high-risk patients are hospitalized as part of their care, the discharge summaries must be completed and signed in a timely manner to ensure availability to all VA clinical staff who will engage in follow-up care.

(2) The arrangement of timely follow-up appointments, increased frequency of sessions (as clinically indicated), and various environmental interventions will be specified. Treatment documentation in any follow-up treatment planning will address risk factors identified in the initial detailed suicide assessment.

(3) Monitoring and treatment for high risk patients must be intensified and will include education about and development of a personal Safety Plan which is consistent with the Recovery Model. The Safety Plan may include elements to address: 1) Recognizing warning signs; 2) Using internal coping strategies; 3) Socializing with family and others for support and distraction; 4) Identifying family and friends to help resolve crisis; 5) Contacting professionals or agencies equipped to help veterans in crisis; 6) Reducing the potential for use of lethal means.

The Safety Plan is available in CPRS in the Mental Health Shared Templates and must be used by the clinician assisting the patient in developing a personal Safety Plan.

(4) Patients should be provided with outpatient follow-up appointments in an appropriate time frame that takes into account individual clinical needs and minimizes risk. Follow-up appointments will be scheduled at a frequency determined by the treating clinician and may include face-to-face individual or group visits, telemental health visits, telephone visits, or in-home visits by specialty staff such as Mental Health Intensive Case Management (MHICM), Community Residential Care (CRC), Homeless Program outreach, Home-Based Primary Care (HBPC), and other staff as appropriate.

h. Ongoing Evaluation of Suicidal Risk:

(1) Inpatient and Residential Care: Treatment providers should re-evaluate suicide risk prior to approving a pass or discharge from inpatient or residential treatment. The decision to grant a pass or discharge should include a risk-benefit analysis to support the clinical decision.

A simple denial of suicidal ideation is insufficient evidence to determine an absence of suicide risk. Staff will complete the Mental Health Suicide Prevention Assessment (refer to Attachment B).

(2) Use of No-Harm Contracts: Research data does not support the effectiveness of a suicide prevention contract or "no-harm contract" as a guarantee that the patient will not engage in self-injurious acts. Therefore, the use of contracts should not be considered a substitute for a careful clinical assessment and tangible means of increasing patient safety through, for example, the use of a Safety Plan. Patients' willingness (or reluctance) to enter into an oral or written suicide prevention contract cannot constitute an absolute indicator of suitability for discharge (or hospitalization).

(3) Safety Plan: Treatment Providers are responsible for periodically reviewing the veteran's safety plan, assisting the veteran to make appropriate adjustments, and encouraging the veteran to utilize the safety plan as a component of ongoing treatment. Provider will give a copy of the safety plan to the patient. Provider will document in CPRS that the safety plan was reviewed with the patient and that a copy was provided to the patient. If appropriate the safety plan can be reviewed with the significant other or family member(s).

(4) Support Systems: When family members or significant others are asked to assist in the monitoring of risk, both patients and family or significant others should be given education and instructions regarding suicide prevention. Instructions should include how to access the treating physician or therapist regarding questions, observations, or concerns during and after normal working hours and any limitations on staff availability. Provider will explain the purpose of the safety plan to family members.

(5) Chronic Suicidality: Some patients have repeated contacts with the health care system for the treatment of self-injurious behavior. Each event should be assessed in the context of the current situation. Although such behaviors may occur without evidence of suicidal intent, all attempts at self-harm should be taken at face value and assessed appropriately.

i. Risk Management: The Suicide Prevention Coordinator will be alerted as an additional signer for notes entered in CPRS regarding patients at risk for suicide. The SPC will review cases and may initiate a Patient Record Flag (PRF) in CPRS denoting suicide risk, as indicated.

Once the PRF is in place, the SPC will document in CPRS explaining precisely why the flag was placed. An electronic progress note MUST accompany each flag. The SPC will be responsible for tracking and establishing follow-up contacts with all veterans who have been assessed as high risk for suicide. Once a PRF is initiated the mental health clinician is responsible for developing a Safety Plan with the patient. The Safety Plan is available in CPRS in the Mental Health Shared Templates and must be used by the clinician assisting the patient in developing a personal Safety Plan. SPC will complete the behavior report on high risk incidents and enter information into SPAN.

(1) The suicide prevention coordinator can be reached at EXT 5873/6019. The SPC can be paged at 629. SPC will be an additional signer on all suicide assessments.

(2) The Suicide Task Force will review cases for the addition or removal of the Suicide Risk Flag.

j. Training:

(1) All VA Medical Center Staff will receive annual training in the identification of veterans at risk for suicide and the procedures for getting immediate help. This training will be a required part of New Employee Orientation.

(a) In addition to the above mentioned training, clinical staff annually will be required to take the LMS course VA 6201 entitled Suicide Risk Assessment for Clinicians.

(2) The VA Medical Center Memphis Director or designee will ensure that all mental health clinical staff has documented competencies in comprehensive suicide risk assessment and on-going management of at-risk individuals. This requirement necessitates the development and utilization of an appropriate tracking system to ensure training compliance.

5. REPORTING REQUIREMENTS: None.

6. RESPONSIBLE OFFICE: Chief, Mental Health Service, under the authority (or auspices), or on behalf of the Chief of Staff.

7. REFERENCES: VISN 9 Directive 10N9-100-07, VISN 9 Management of Patients at Risk for Suicide, dated December 14, 2007. VHA Directive 2003–048, National Patient Records Flags, dated August 28, 2003. JCAHO 2007 National Patient Safety Goal (15A). IL 10-2006-013, Under Secretary for Health’s Information Letter, New JCAHO Performance Requirement for Mitigating the Risk of Suicide, dated December 11, 2006. VHA HANDBOOK 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, dated September 11, 2008. Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version (Draft), Office of Mental Health Services, VA Central Office, dated August 8, 2008.

8. RESCISSION: Medical Center Policy Memorandum 116A-12, dated November 16, 2016.

Medical Staff Concurrence: Date: February 26, 2018

/s/

THOMAS C. FERGUSON, M.D.

Chief of Staff

/s/

DAVID K. DUNNING, MPA

Medical Center Director

Attachments

Attachment A Policy Memorandum 116A-12 Date: February 26, 2018

ASSESSMENT OF SUICIDE RISK FACTORS:

Non-Mental Health

__The ASRF is completed today because:

__ Patient states or alludes to suicidal thoughts and/or is hesitant about answering questions regarding suicidality.

__ The depression screen is positive.

__ The patient presents with symptoms/signs of depression, acute anxiety, psychosis, substance abuse, or significant emotional distress.

__ A family member expresses concern regarding the patient's safety or psychological status.

I. IDENTIFY PROTECTIVE FACTORS:

__ Patient is unable to identify protective factors against suicide.

__ Protective factors identified by patient and/or provider (check all that apply):

__ Good social support __ Stated hopefulness and planning for future, including short and long-term plans __ Religious/spiritual coping/belief system __ Restricted access to highly lethal methods of suicide __ No demographic risk factors __ Positive engagement with dependent children __ Current employment __ Dependable sources of income __ Established relationship with Mental Health Provider __ Established relationship with Primary Care Provider __ Other:

II. ASSESS LEVEL OF RISK:

1. Assess for IMMINENT RISK: (Check all that apply)

__ Patient expresses current suicidal ideation AND has a rational suicide plan AND the lethal means to carry it out.

__ Patient presents following suicide attempt.

__ Patient expresses suicidal ideation AND has compromised mental status (e.g., secondary to substance intoxication, delirium).

__ Patient is acutely psychotic AND expressing suicidal ideation.

**IF ANY OF THE ABOVE IS CHECKED, PATIENT IS AT IMMINENT RISK. DO NOT LEAVE

PATIENT ALONE. Patient at imminent risk will also be monitored at all times, including when using the restrooms. HOSPITALIZATION AND/OR INITIATION OF SUICIDE PRECAUTIONS

ARE REQUIRED. INDICATE DISPOSITION BELOW.

**IF NONE OF THE ABOVE IS CHECKED, ASSESS FOR NEXT LEVEL OF RISK.

Date: February 26, 2018 Assessment:

__Patient is assessed to be at Imminent Risk.

__Patient is assessed NOT to be at Imminent Risk.

Disposition for Imminent Risk Patient:

__ Patient has been medically cleared for direct admission to inpatient psychiatry. Inpatient unit contacted and attending psychiatrist notified of admission. Patient escorted to the unit.

__ Patient refused voluntary admission. Patient has been medically cleared and Certificate of Need for emergency admission initiated. Inpatient unit and attending psychiatrist notified of admission. Patient escorted to the unit.

__ Patient is currently hospitalized for medical/surgical care. Patient placed on 1:1 suicide precautions. Psychiatry C&L team or POD contacted. Patient will be reassessed prior to change in level of precautions and/or discharge.

2. Assess for HIGH RISK: (Check all that apply)

__ Patient reports current suicidal ideation (with or without plan) __ Family/caregiver reports that patient has expressed suicidal ideation but patient now denies.

__ Patient has recently written suicide notes, constructed a will, or has given away possessions but denies suicidal ideation.

__ Patient has recent (past two weeks) suicidal ideation with past attempts but now denies.

__ Patient has recent suicidal ideation and is unable to identify protective factors or buffers against suicide.

__ Patient has recent suicidal ideation and psychiatric hospitalization within the past year.

__ Patient reports hearing voices telling him/her to commit suicide.

**IF ANY OF THE ABOVE IS CHECKED, PATIENT IS AT HIGH RISK. DO NOT LEAVE THE

PATIENT ALONE. Patient at high risk will also be monitored at all times, including when using the restrooms. A MENTAL HEALTH PROVIDER MUST ASSESS PATIENT’S PSYCHIATRIC

NEEDS TODAY. INDICATE DISPOSITION BELOW.

**IF NONE OF THE ABOVE IS CHECKED, ASSESS FOR NEXT LEVEL OF RISK.

Assessment:

__Patient is assessed to be at High Risk.

__Patient is assessed NOT to be at High Risk.

Disposition for High Risk Patient:

__ Patient's Mental Health Provider of record contacted and will evaluate the patient. Pt. to remain on 1:1 suicide precautions until evaluated.

__ Mental Health Provider assigned to this clinic has been contacted and will evaluate the patient. Pt. to remain on 1:1 suicide precautions until evaluated.

__There is no available Mental Health Provider assigned to this patient or clinic. MHC provider on call for emergency screenings (or POD for after hours) contacted and will evaluate the patient. Pt. to remain on 1:1 suicide precautions until evaluated.

Date: February 26, 2018

__ Patient is hospitalized for medical/surgical care. Pt. to remain on 1:1 suicide precautions until evaluated. Psychiatry C&L team or POD contacted and will evaluate the patient.

3. Assess for MODERATE RISK:

__Patient denies suicidal ideation but presents today with significant/acute psychiatric symptoms

AND

__Patient has at least one of the following suicide risk factors: (Check all that apply) __unreliable support system/few family ties __no verbalized protective factors __chronic pain __impulsive behavior by history __recent psychiatric hospitalization __history of suicide attempt __family history of suicide or exposure to someone else's death by suicide __chronic medical problems __no place to live __significant psychosocial stressors (e.g., serious financial problems) __recent losses (e.g., job, relationship, death in family)

**IF BOTH OF THE ABOVE ARE CHECKED PATIENT IS AT MODERATE RISK. PATIENT

REQUIRES APPOINTMENT WITHIN 14 DAYS WITH A MENTAL HEALTH PROVIDER OR

INITIATION OF TREATMENT BY PCP. INDICATE DISPOSITION BELOW.

**IF NONE OF THE ABOVE IS CHECKED, ASSESS FOR NEXT LEVEL OF RISK.

Assessment:

__Patient is assessed to be at Moderate Risk.

__Patient is assessed NOT to be at Moderate Risk.

Disposition for Moderate Risk Patient:

__Mental Health Provider of record contacted. Appointment scheduled or provider will contact the patient directly for scheduling.

__There is no provider of record. Mental Health Provider assigned to this clinic/service area contacted. Appointment scheduled or provider will contact patient directly for scheduling.

__There is no provider of record or Mental Health Provider assigned to this service area. Mental Health Clinic consult initiated.

__PCP to follow patient. Appropriate treatment (e.g., medication trial) initiated and follow-up scheduled for monitoring.

__ Patient and/or family provided crisis information and resources, including the National Suicide Prevention crisis line number.

4. Assess for LOW RISK:

__Patient has no acute psychiatric symptoms, is not suicidal and has no indicated risk factors.

__Patient has mild psychiatric symptoms, is not suicidal and has no indicated risk factors.

__Patient has an established psychiatric diagnosis, is not suicidal, and is currently stable.

Date: February 26, 2018 Assessment:

__Patient is assessed to be at Low Risk.

Disposition for Low Risk Patient:

__Patient does not currently need mental health services. Patient instructed to call for questions, concerns, and/or increase in symptoms.

__PCP will monitor for increase in symptoms.

__PCP will initiate treatment and monitor appropriately.

__Patient will follow-up with his/her Mental Health Provider of record.

__Patient requests psychotherapy/counseling services. Appropriate consult initiated.

__Prescribing provider alerted regarding need for medication renewal.

__Psychiatric medications renewed.

Attachment B

ASSESSMENT OF SUICIDE RISK FACTORS

Mental Health Provider

RISK OF HARM:

1. Suicidal ideation:

__ Yes (specify):

__ Denies

2. Intent:

__ Yes (specify):

__ Denies

3. Plan:

__ Yes (specify):

__ Denies

4. Risk Factors (Check all that apply):

__ Prior attempt(s) __ Family history of suicide __ Psychiatric diagnosis __ Active psychosis __ Acute distress __ Delirium __ Recent psychiatric hospitalization __ Active substance use __ Age (less than 25, older then 65) __ Male gender __ Minimal social support __ Chronic pain __ Impulsive behavior by history __ Chronic medical problems __ Homeless __ Significant psychosocial stressors (e.g., serious financial problems) __ Recent losses (e.g., job, relationship, death in family) __ No verbalized protective factors __ Unable to participate in treatment planning __ Other:

5. Protective Factors:

__ Patient is unable to identify protective factors __ Protective factors identified by patient and/or provider (check all that apply):

__ Good social support __ Stated hopefulness and planning for future, including short and long-term plans __ Religious/spiritual coping/belief system __ Restricted access to highly lethal methods of suicide __ No demographic risk factors __ Positive engagement with dependent children __ Current employment

Attachment B

__ Dependable sources of income __ Established relationship with Mental Health Provider __ Established relationship with Primary Care Provider __ Participates actively in treatment planning or program

6. Assessed Level of Risk (Check one):

__Imminent (specify):

__High (specify):

__Moderate (specify):

__Low (specify):

7. Intervention (Check all that apply):

__Admit to inpatient psychiatry __Admit to SARRTP __Initiate Certificate of Need __Place on 1:1 (line of sight) supervision __Place on 1:1 (arms length) supervision __Place on 15 minute checks __Place on 30 minute checks __Discontinue suicide precautions __Medication initiated or adjusted (specify):

__Follow-up scheduled (specify):

__Safety plan developed/reviewed (specify):

__Other:

Attachment C

GUIDE FOR RESPONDING TO SUICIDAL CALLERS

The Guide for Responding to Suicidal Callers is printed on card stock measuring 5” wide by 8" long. On the obverse is printed “SUICIDE CALLER” in font size 72.

ALL STAFF-- IN ORDER TO ROUTE HELP TO YOUR LOCATION THE FOLLOWING

PROTOCOL WILL BE USED:

I work in Building _______________; I am located in room _________;

My Ext. no. is __________; My department is ___________________

I have received a phone call from a possible suicidal patient.

CO-WORKER IS PRESENT SCENARIO:

1. SIGNAL YOUR CO-WORKER! _______________

2. Try to get the following information: _______________

• Caller’s Name; last 4; Location; Phone Number _______________

3. Keep the caller talking - remind/ask the patient: _______________

• “I want to help you stay safe”. _____________________________

• “How are you feeling?” _____________________________

• “Tell me what is going on”. _____________________________

4. Prepare the caller for a MH Expert coming to the phone

IF MH EXPERT CAN NOT COME PREPARE TO TRANSFER CALL:

5. To transfer to the MH Expert:

• Assure caller you do not want to lose the call

• Repeat their call-back number

• Press “FLASH” enter the ext. that your co-worker has received

• Wait for answer and tell the MH Expert the caller’s name

• Press “CONF” and greet both the caller and MH Expert

• Once the MH Expert has call – thank the caller and hang-up

CO-WORKER DUTIES FOR THE ABOVE SCENARIO:

1. Fellow employee gets your attention.

2. Go to your extension and call “33” for immediate operator assistance (at North or South

CBOC call your onsite mental health provider).

Attachment C Policy Memorandum 116A-12 Date: February 26, 2018

• Identify yourself to the operator

• Identify the extension you are calling from

• Tell him/her that you have a POSSIBLE SUICIDE on the phone

• (operator will page 555 STAT and give them your information)

3. Stay with your phone and await the MH Expert’s return call

• Identify where you are located; how to get there

4. Let your fellow employee know the MH Expert is on the way

• Assist your fellow employee until the MH Expert arrives

5. Assist your fellow employee if the call must be transferred

NO CO-WORKER IS AVAILABLE SCENARIO:

1. Try to get the following information:

• Caller’s Name; last 4; Location; Phone Number

2. Keep the caller talking - remind/ask the patient:

• “I want to help you stay safe”.

• “How are you feeling?”

• “Tell me what is going on”.

3. Prepare the caller for your need to get someone to help you

4. Press “FLASH” - Dial 33 for immediate operator assistance

5. Tell him/her that you have a POSSIBLE SUICIDE on the phone

6. Give them your location by building, room number and department

7. Allow the operator to hang up;

8. Press “CONNECT” this returns you to the caller

9. Try to keep the caller on the phone until the MH Expert arrives

Attachment D

VA SAFETY PLAN -QUICK GUIDE FOR CLINICIANS

WHAT IS A SAFETY PLAN?

A Safety Plan is a prioritized written list of coping strategies and sources of support veterans can use who have been deemed to be at high risk for suicide. Veterans can use these strategies before or during a suicidal crisis. The plan is brief, is in the veteran’s own words, and is easy to read.

WHO SHOULD HAVE A SAFETY PLAN?

Any veteran who has a suicidal crisis should have a comprehensive suicide risk assessment.

Clinicians should then collaborate with the veteran on developing a safety plan.

HOW SHOULD A SAFETY PLAN BE DONE?

Safety Planning is a clinical process. Listening to, empathizing with, and engaging the veteran in the process can promote the development of the Safety Plan and the likelihood of its use.

IMPLEMENTING THE SAFETY PLAN

There are 6 Steps involved in the development of a Safety Plan:

VA Safety Plan: Brief Instructions Step 1: Warning Signs

• Ask “How will you know when the safety plan should be used?”

• Ask, “What do you experience when you start to think about suicide or feel extremely distressed?”

• List warning signs (thoughts, images, thinking processes, mood, and/or behaviors) using the veteran’s own words.

Step 2: Internal Coping Strategies

• Ask “What can you do, on your own, if you become suicidal again, to help yourself not to act on your thoughts or urges?”

• Assess likelihood of use: Ask “How likely do you think you would be able to do this step during a time of crisis?”

• If doubt about use is expressed, ask “What might stand in the way of you thinking of these activities or doing them if you think of them?”

• Use a collaborative, problem solving approach to address potential roadblocks and ID alternative coping strategies.

Step 3: Social Contacts Who May Distract from the Crisis

• Instruct veterans to use Step 3 if Step 2 does not resolve the crisis or lower risk.

• Ask “Who or what social settings help you take your mind off your problems at least for a little while? “Who helps you feel better when you socialize with them?”

• Ask for safe places they can go to do be around people (e.g. coffee shop).

• Ask veteran’s to list several people and social settings, in case the first option is unavailable.

• Remember, in this step, the goal is distraction from suicidal thoughts and feelings.

• Assess likelihood that veteran will engage in this step; ID potential obstacles, and problem solve, as appropriate.

Step 4: Family Members or Friends Who May Offer Help

• Instruct veterans to use Step 4 if Step 3 does not resolve the crisis or lower risk.

• Ask “Among your family or friends, who do you think you could contact for help during a crisis?” or “Who is supportive of you and who do you feel that you can talk with when you’re under stress?”

• Ask veterans to list several people, in case one contact is unreachable. Prioritize the list. In this step, unlike the previous step, patients reveal they are in crisis.

• Assess likelihood veteran will engage in this step; ID potential obstacles, and problem solve, as appropriate.

• Role-play and rehearsal can be very useful in this step.

Step 5: Professionals and Agencies to Contact for Help

• Instruct veterans to use Step 5 if Step 4 does not resolve the crisis or lower risk.

• Ask “Who are the mental health professionals that we should identify to be on your safety plan?” and “Are there other health care providers?”

• List names, numbers and/or locations of clinicians, local urgent care services, VA

Suicide Prevention Coordinator, VA Suicide Prevention Hotline (1-800-273-TALK (8255)).

• Assess likelihood veteran will engage in this step; ID potential obstacles, and problem solve, as appropriate.

Step 6: MAKING THE ENVIRONMENT SAFE

• Ask veterans which means they would consider using during a suicidal crisis.

• Ask: “Do you own a firearm, such as a gun or rifle?” and “What other means do you have access to and may use to attempt to kill yourself?”

• Collaboratively identify ways to secure or limit access to lethal means: Ask

“How can we go about developing a plan to limit your access to these means?”

• For methods with low lethality, clinicians may ask veterans to remove or restrict their access to these methods themselves.

• Restricting the veterans’ access to a highly lethal method, such as a firearm, should be done by a designated, responsible person—usually a family member or close friend, or the police.

Policy Memorandum 116A-12 Date: February 26, 2018

WHAT ARE THE STEPS AFTER THE PLAN IS DEVELOPED?

• Assess the likelihood that the overall safety plan will be used and problem solve with the veteran to identify any barriers or obstacles to using the plan.

• Discuss where the veteran will keep the safety plan and how it will be located during a crisis

• Evaluate if the format is appropriate for the veterans’ capacity and circumstances

• Review the plan periodically when veteran’s circumstances or needs change

REMEMBER: THE SAFETY PLAN IS A TOOL TO ENGAGE THE VETERAN AND IS ONLY

ONE PART OF A COMPREHENSIVE SUICIDE CARE PLAN

Clinicians are strongly advised to read the manual, “VA Safety Plan Treatment Manual to Reduce Suicide Risk,” and review associated video training materials at the following link:

http://vaww.mentalhealth.va.gov/files/suicideprevention/VA_Safety_planning_manual_8-19- 08revisions.doc

SAFETY PLAN: VA VERSION

Instructions: Complete and review safety plan with patient. Ensure patient understands the purpose of a safety plan and provide him/her a copy. Also, indicate if family member was/was not available to discuss plan.

Step 1: Warning Signs:

1._________________________________________________________________________________ 2._________________________________________________________________________________ 3._________________________________________________________________________________

Step 2: Internal coping strategies – Things I can do to take my mind off my problems without contacting another person:

1._________________________________________________________________________________ 2._________________________________________________________________________________ 3._________________________________________________________________________________

Step 3: People and social settings that provide distraction:

1. Name____________________________________________ Phone_________________________

2. Name____________________________________________ Phone_________________________

3. Place______________________________________ 4. ____________________________________

Step 4: People whom I can ask for help:

1. Name____________________________________________ Phone_________________________

2. Name____________________________________________ Phone_________________________

3. Name____________________________________________ Phone_________________________

Step 5: Professionals or agencies I can contact during a crisis:

1. Clinician Name________________________________________ Phone _______________________ Clinician Pager or Emergency Contact # _________________________________________________

2. Clinician Name _______________________________________ Phone ________________________ Clinician Pager or Emergency Contact # _________________________________________________

3. Local Urgent Care Services ___________________________________________________________ Urgent Care Services Address _________________________________________________________ Urgent Care Services Phone __________________________________________________________

4. VA Suicide Prevention Resource Coordinator Name _______________________________________ VA Suicide Prevention Resource Coordinator Phone _______________________________________

5. VA Suicide Prevention Hotline Phone: 1-800-273-TALK (8255), push 1 to reach a VA mental health clinician

Step 6: Making the environment safe:

1. _________________________________________________________________________________

2. _________________________________________________________________________________

Safety Plan Treatment to Reduce Suicide Risk: Veteran Version (Stanley & Brown, 2008).

Attachment E

This Patient Safety Alert AL15-03 replaces and supersedes Patient Safety Advisory AD08-03 issued on July 7, 2008, and revised on May 2, 2011

A Safety Plan is a prioritized written list of coping strategies and sources of support veterans can use who have been deemed to be at high risk for suicide. Veterans can use these strategies before or during a suicidal crisis. The plan is brief, is in the veteran’s own words, and is easy to read.

Item: Revised voicemail greetings for VA desk phones and VA cell phones issued to mental health staff members Specific Incident: Patient Safety Advisory AD08-03 resulted from a Veterans Integrated Service Network (VISN) report that Veterans left messages on phones that were assigned to mental health staff members, but patients attempted or completed suicide prior to mental health staff members’ ability to return the phone calls. Patient Safety Advisory AD08-03 provided recommendations to mitigate the risk that Veterans in crisis could be waiting for a return call. Patient Safety Advisory AD08-03 is being replaced with this Patient Safety Alert (AL15-03) to mandate specific actions in order to prevent harm to patients.

General Information: Because it is possible to bypass switchboard greetings by entering extensions or by directly dialing mental health staff members’ phone numbers, Veterans may directly reach phones for mental health staff members that are not answered 24 hours a day/7days a week. For any mental health phone not answered, it is imperative that Veterans hear instructions for making emergency contact with 911 and the Veterans Crisis Line.

Actions: 1. By Close of Business (COB) August 31, 2015, the Medical Center Director (or designee) shall ensure that the Chief of Mental Health (or facility equivalent) and all mental health staff members are made aware of this Patient Safety Alert.

2. By COB September 14, 2015, the Chief of Mental Health or facility equivalent (or designee) shall ensure that VA desk phones (including landline and Voice over Internet Protocol (VoIP) devices – see Additional Information) and VA cell phones (including Blackberry devices and VoIP devices) issued to mental health staff members include the exact, recently revised wording, shown below in BOLD, CAPITALIZED RED TEXT, for their activated voicemail message, including when voicemail messages are changed for out of office situations (e.g., leave, travel). AL15-03 Two examples of voicemail messages that include the mandatory language are as follows. The bold, capitalized red text is mandatory; however, the italicized text following the bold, capitalized red text can be personalized according to your needs and may vary (i.e., the italicized text does not have to be the exact wording as shown in the examples).

Example 1, standard greeting: “HELLO. YOU HAVE REACHED THE PHONE OF [INSERT NAME AND

TITLE]. IF YOU ARE HAVING A MEDICAL OR MENTAL HEALTH EMERGENCY, HANG UP AND DIAL

911. IF YOU ARE HAVING THOUGHTS OF SUICIDE, PLEASE HANG UP AND CALL 1-800-273-8255, THEN PRESS 1 AT THE PROMPT TO REACH THE VETERANS CRISIS LINE. THAT NUMBER AGAIN

IS 1, 800, TWO, SEVEN THREE, EIGHT, TWO, FIVE, FIVE, AND THEN PRESS 1 FOR THE VETERANS CRISIS LINE. Otherwise, please leave a brief message and I will return your call when I am able during regular business hours.”

Example 2, out of office greeting: “HELLO. YOU HAVE REACHED THE PHONE OF [INSERT NAME AND

TITLE]. IF YOU ARE HAVING A MEDICAL OR MENTAL HEALTH EMERGENCY, HANG UP AND DIAL

911. IF YOU ARE HAVING THOUGHTS OF SUICIDE, PLEASE HANG UP AND CALL 1-800-273-8255, THEN PRESS 1 AT THE PROMPT TO REACH THE VETERANS CRISIS LINE. THAT NUMBER AGAIN

IS 1, 800, TWO, SEVEN, THREE, EIGHT, TWO, FIVE, FIVE, AND THEN PRESS 1 FOR THE

VETERANS CRISIS LINE. I am out of the office, returning August 31st. I will not have access to voicemail.

Please leave a brief message and I will return your call when I am back in the office.”