ATTACHMENT 19 - Suicide Risk (Suicidality)_CDS Content White Paper_2019-01-02.pdf

Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-

Compliant Knowledge Artifacts (KNARTs)

Mental Health: Suicidality Clinical Content White Paper

Department of Veterans Affairs (VA)

Knowledge Based Systems (KBS)

Office of Informatics and Information Governance (OIIG) Clinical Decision Support (CDS) ii

Revision Table

Date Revision Description Author

May 2018 1.0 Document submitted by B3 B3, KBS team, VA clinical SMEs

1/2/19 2.0 Document approved by VA clinical leadership

Linda, VA clinical leadership

2/18/19 3.0 Document published by CDS Connect

CDS Connect, KBS team, Pivotal

Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs): Mental Health:

Suicidality Clinical Content White Paper by Department of Veterans Affairs (VA)

Publication date May 2018 Copyright © 2018 B3 Group, Inc.

Copyright © 2018 Cognitive Medical Systems, Inc.

B3 Group, Inc.

NOTICE OF GOVERNMENT COPYRIGHT LICENSE AND UNLIMITED RIGHTS LICENSE

Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except in compliance with the License.

You may obtain a copy of the License at http://www.apache.org/licenses/LICENSE-2.0 Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.

See the License for the specific language governing permissions and limitations under the License.

Portions of this content are derivative works from content produced by Cognitive Medical Systems, Inc. licensed under the Apache License, Version 2.0.

Additional portions of this content are derivative works from content contributed by Motive Medical Intelligence Inc., under Creative Commons Attribution-ShareAlike 4.0.

Contributions from 2013-2018 were performed either by US Government employees, or under US Veterans Health Administration contracts.

US Veterans Health Administration contributions by government employees are work of the U.S. Government and are not subject to copyright protection in the United States. Portions contributed by government employees are USGovWork (17USC §105). Not subject to copyright.

See: https://www.usa.gov/government-works Contribution by contractors to the US Veterans Health Administration during this period are contractually contributed under the Apache License, Version 2.0 and US Government sponsorship is acknowledged under Contract VA118-16-D-1008, Task Order VA11817F10080007.

Cognitive Medical Systems, Inc.

Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except in compliance with the License.

You may obtain a copy of the License at http://www.apache.org/licenses/LICENSE-2.0 Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.

See the License for the specific language governing permissions and limitations under the License.

This and related content produced by Cognitive Medical Systems, Inc. licensed under the Apache License, Version

2.0 is available at: https://bitbucket.org/cogmedsys/hl7-kas-examples Additional portions of this content are derivative works from content contributed by Motive Medical Intelligence Inc., under Creative Commons Attribution-ShareAlike 4.0. https://bitbucket.org/cogmedsys/kas-source-material Contributions from 2013-2018 were performed either by US Government employees, or under US Veterans Health Administration contracts.

US Veterans Health Administration contributions by government employees are work of the U.S. Government and are not subject to copyright protection in the United States. Portions contributed by government employees are USGovWork (17USC §105). Not subject to copyright. See: https://www.usa.gov/government-works Contribution by contractors to the US Veterans Health Administration during this period are contractually contributed under the Apache License, Version 2.0 and US Government sponsorship is acknowledged under Contract VA118-16-D-1008-0007.

iv

Contract: VA118-16-D-1008, Task Order (TO): VA-118-16-F-1008-0007

Table 1. Relevant KNART Information - Mental Health: Suicidality

Mental Health KNART Associated CLIN Suicide Risk Screen – Documentation Template CLIN0005AB Positive Suicide Risk Screening – Order Set CLIN0008BA v

Table of Contents VA Subject Matter Expert (SME) Panel ........................................................................................................ viii

VA Knowledge Based Systems (KBS) Office Project Contributors ............................................................... viii

Contributing Contractors ................................................................................................................................. ix Introduction...................................................................................................................................................... x

Conventions Used ........................................................................................................................................... xi Chapter 1. Mental Health: Suicidality

1.1. Clinical Context

1.2. Knowledge Artifacts

Chapter 2. Documentation Template – Suicide Risk Assessment

2.1. Knowledge Narrative

2.2. Reason for Visit

2.3. Screening

2.4. Secondary Screen [Columbia-Suicide Severity Rating Scale (C-SSRS) Screen]

2.5. Plan

2.6. Patient and Caregiver Education

Chapter 3. Order Set: Positive Suicide Risk Screening

3.1. Knowledge Narrative

3.2. Consults

3.3. Follow up

Bibliography/Evidence Appendix A. Existing Sample VA Artifacts

Appendix B. Acronyms vi

List of Figures

A.1. Reminder Dialog Template: Suicide Risk Assessment (Image 1 of 5) A.2. Reminder Dialog Template: Suicide Risk Assessment (Image 2 of 5) A.3. Reminder Dialog Template: Suicide Risk Assessment (Image 3 of 5) A.4. Reminder Dialog Template: Suicide Risk Assessment (Image 4 of 5) A.5. Reminder Dialog Template: Suicide Risk Assessment (Image 5 of 5) A.6. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 1 of 6) A.7. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 2 of 6) A.8. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 3 of 6) A.9. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 4 of 6) A.10. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 5 of 6) A.11. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 6 of 6) A.12. Safety Plan (Image 1 of 20) A.13. Safety Plan (Image 2 of 20) A.14. Safety Plan (Image 3 of 20) A.15. Safety Plan (Image 4 of 20) A.16. Safety Plan (Image 5 of 20) A.17. Safety Plan (Image 6 of 20) A.18. Safety Plan (Image 7 of 20) A.19. Safety Plan (Image 8 of 20) A.20. Safety Plan (Image 9 of 20) A.21. Safety Plan (Image 10 of 20) A.22. Safety Plan (Image 11 of 20) A.23. Safety Plan (Image 12 of 20) A.24. Safety Plan (Image 13 of 20) A.25. Safety Plan (Image 14 of 20) A.26. Safety Plan (Image 15 of 20) A.27. Safety Plan (Image 16 of 20) A.28. Safety Plan (Image 17 of 20) A.29. Safety Plan (Image 18 of 20) A.30. Safety Plan (Image 19 of 20) A.31. Safety Plan (Image 20 of 20) vii

List of Tables

1. Relevant KNART Information - Mental Health: Suicidality ........................................................ iii

2. VA Subject Matter Expert (SME) Panel ..................................................................................... vii

1.1. Clinical Context Domains

viii

VA Subject Matter Expert (SME) Panel

Name Title Project Role Rani Hoff

PhD, MPH

Director, Northeast Program Evaluation Center Office of Mental Health and Suicide Prevention (10NC5) VA Central Office

Professor of Psychiatry

Yale University School of Medicine

SME, Primary

Bridget Matarazzo Director of Clinical Services

Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC)

Denver, CO 80220

SME, Secondary

Ira Katz Senior Consultant for Mental Health Program Analysis

SME

Edd Post

VA HSR&D

2215 Fuller Road

Ann Arbor, MI 48105

SME

VA Knowledge Based Systems (KBS) Office Project Contributors

KBS Team Team Members Clinical Decision Support Diane Montella, MD; Apurva Desai, LL.M, M.S., PMP; David Douglas, MD; Jorge Ferrer, MD, MBA, LSA; Elena Smyly, PMP; Catherine Staes, RN, MPH, PhD; Linda Wedemeyer, MD, RN, MS; Scott Wood, PhD

Informatics Architecture Keith Campbell, MD; Stephanie Klepacki Terminology Michael Lincoln, MD; Catherine Hoang, MS, RN; Cecelia Bowen, MBA, RHIA; Sarita Keni, MD; John Kilbourne, MD; Melanie Loucks, MA;

Sarah Maulden, MD, MS; Holler Miller, MS, BSN; Loren Stevenson, MD;

Brenda Washington

VA Subject Matter Expert (SME) Panel ix

Contributing Contractors

Team Contractors Project Contract Team (Contract Number VA-118- 16-F-1008-0007)

B3 Group, Inc. (Prime) Cognitive Medical Systems (Sub) Motive Medical Intelligence Inc., (Sub)

KBS Terminology Team Contract Terminology Support

JP Systems, Inc. (Prime) Deloitte Touche, LLP (Sub)

KBS Program Management Contract Support SAMS, Inc. (Prime) Pivotal Insight, LLC (Sub) x

Introduction

The VA is committed to improving the ability of clinicians to provide care for patients while increasing quality, safety, and efficiency. Recognizing the importance of standardizing clinical knowledge in support of this goal, VA is implementing the Health Level 7 (HL7) Knowledge Artifact Specification for a wide range of VA clinical use cases. Knowledge Artifacts, referred to as (KNARTs), enable the structuring and encoding of clinical knowledge so the knowledge can be integrated with electronic health records to enable clinical decision support.

The purpose of this Clinical Content White Paper (CCWP) is to capture the clinical context and intent of KNART use cases in sufficient detail to provide the KNART authoring team with the clinical source material to construct the corresponding knowledge artifacts using the HL7 Knowledge Artifact Specification. This paper has been developed using material from a variety of sources: VA artifacts, clinical practice guidelines, evidence in the body of medical literature, and clinical expertise. After reviewing these sources, the material has been synthesized and harmonized under the guidance of VA subject matter experts to reflect clinical intent for this use case.

Unless otherwise noted, items within this white paper (e.g., documentation template fields, orderable items, etc.)

are chosen to reflect the clinical intent at the time of creation. To provide an exhaustive list of all possible items and their variations is beyond the scope of this work.

xi

Conventions Used

Conventions used within the knowledge artifact descriptions include:

<obtain>: Indicates a prompt to obtain the information listed

• If possible, the requested information should be obtained from the underlying system(s). Otherwise, prompting the user for information may be required

• The technical and clinical notes associated with a section should be consulted for specific constraints on the information (e.g., time-frame, patient interview, etc.)

• Default Values: Unless otherwise noted, <obtain> indicates to obtain the most recent observation. It is recognized that this default time-frame value may be altered by future implementations

[...]: Square brackets enclose explanatory text that indicates some action on the part of the clinical user, or general guidance to the clinical or technical teams. Examples include, but are not limited to:

[Begin ...], [End ...]: Indicates the start and end of specific areas to clearly delineate them for technical purposes.

[Activate ...]: Initiates another knowledge artifact or knowledge artifact section.

[Section Prompt: ...]: If this section is applicable, then the following prompt should be displayed to the user.

[Section Selection Behavior: ...]: Indicates technical constraints or considerations for the selection of items within the section.

[Attach: ...]: Indicates that the specified item should be attached to the documentation template if available.

[Link: ...]: Indicates that rather than attaching an item, a link should be included in the documentation template.

[Clinical Comment: ...]: Indicates clinical rationale or guidance.

[Technical Note: ...]: Indicates technical considerations or notes.

[If ...]: Indicates the beginning of a conditional section.

[Else, ...]: Indicates the beginning of the alternative branch of a conditional section.

[End if ...]: Indicates the end of a conditional section.

☐: Indicates items that should be selected based upon the section selection behavior.

Chapter 1. Mental Health: Suicidality

1.1. Clinical Context

[Begin Clinical Context.]

[Clinical Comment: Intended to support documentation of screening-related findings and decisions; and support initiation of appropriate clinical orders. The documentation template supports documentation of findings and decisions from screening for suicide risk, including options for using the Patient Health Questionnaire (PHQ), suicidality-related components of a mental health intake assessment, and suicide risk assessment.

VA clinical practice guidelines for suicide risk screening and management are regarded as the preferred source.]

Table 1.1. Clinical Context Domains

Target User Mental health providers; other physicians and nurses performing screening

Patient Patients identified as being at risk for suicide;

members of patient cohorts identified for suicide risk screening

Priority Routine Specialty Mental Health Primary Care Location Outpatient

[End Clinical Context.]

1.2. Knowledge Artifacts

[Begin Knowledge Artifacts.]

This section describes the CDS knowledge artifacts that are specific to the Suicide Risk Screening clinical use case. These artifacts include the Documentation Template and the Order Set and are described in detail in the following sections.

• A Documentation Template: Mental Health: Suicide Risk Assessment KNART

• Documents the results of screening for suicide risk

• Includes logic for appropriate display of documentation sections

• An Order Set: Positive Suicide Risk Screening KNART

• Orderable items determined to be appropriate based on the findings and decisions recorded in the Suicide Risk Screening documentation template KNART

[End Knowledge Artifacts.]

Chapter 2. Documentation Template – Suicide Risk Assessment

[Begin Documentation Template – Suicide Risk Assessment.]

2.1. Knowledge Narrative

[Begin Knowledge Narrative.]

[See Clinical Context in Chapter 1.]

Suicide and self-directed violence are prevalent problems among veterans, who account for a significant proportion of deaths by suicide in the United States. In light of this, the VA has established the VA-Suicide Prevention and Application Network (SPAN) to coordinate the identification and reporting of suicide-related events, to facilitate the identification of individuals at high risk, to target interventions, and to support program planning and evaluation. Further efforts to address the problem systematically have the potential to improve the identification and treatment of veterans who are at increased risk of suicide.

[Technical Note: This documentation template should be available to mental health providers and other physicians and nurses caring for patients identified as being at risk for suicide or identified for suicide risk screening.]

[End Knowledge Narrative.]

2.2. Reason for Visit

[Begin Reason for Visit.]

<obtain> Reason for patient encounter in the VA today

[End Reason for Visit.]

2.3. Screening

[Begin Screening.]

[Technical Note: Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire2+Ideation9 (PHQ2+I9) scores from the past 1 year should be presented to the user, with the dates of those scores, from available data.]

[Section Prompt: Patient Health Questionnaire2+Ideation9 (PHQ2+I9)

[Technical Note: Patient Health Questionnaire2+Ideation9 (PHQ2+I9) calculates 2 scores, 1 for the PHQ2 and a separate score for question 9 on the PHQ-9. Scores are calculated by totaling the form label values (indicated by a number following each response option) for the form labels selected by the user. Note that the following form components are adapted from Kroenke 2001.]

[Technical Note: PHQ2+I9 is defined as the PHQ2 (questions 1 and 2 from the PHQ-9), in addition to question 9 from PHQ-9.]

[Section Prompt: Patient Health Questionnaire2+Ideation9 (PHQ2+I9) is 3 questions, and scores are calculated separately for questions 1 and 2 (PHQ-2), and then for the 3rd question (question 9 on the PHQ-9) by totaling the numbers following response options below. A positive depression screen is defined as a total score of 3 or more on the first 2 questions, and a positive suicide screen is defined as any score above 0 on the third question.

[Section Prompt: Information on the PHQ-9 is available here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/.]

[Section prompt: Ask the patient the following questions:]

[Section Prompt: “Over the past two weeks, how often have you been bothered by any of the following problems?”]

Documentation Template – Suicide Risk Assessment

[Section Prompt: Little interest or pleasure in doing things?]

[Section Selection Behavior: Select one. Required.]

☐ Not at all (score =0)

☐ Several days (score =1)

☐ More than half the days (score =2)

☐ Nearly every day (score =3)

[Section Prompt: Feeling down, depressed, or hopeless?]

[Section Selection Behavior: Select one. Required.]

☐ Not at all (score =0)

☐ Several days (score =1)

☐ More than half the days (score =2)

☐ Nearly every day (score =3)

[Technical Note: A score weighting > 0 on the following question constitutes a positive suicide screen.]

[Section Prompt: Thoughts that you would be better off dead or of hurting yourself in some way?]

[Section Selection Behavior: Select one. Required.]

☐ Not at all (score =0)

☐ Several days (score =1)

☐ More than half the days (score =2)

☐ Nearly every day (score =3)

[Section Prompt: PHQ-2 score]

<Obtain> PHQ-2 score

[Section Prompt: PHQ-2 results (positive or negative)]

<Obtain> PHQ-2 results (positive or negative)

[Technical Note: Results are calculated as per the second section prompt in this section.]

[Section Prompt: For a positive PHQ-2 consider the following:]

[Technical Note: Upon completion of the PHQ-2, if the PHQ-2 was positive, the user should be presented with links to the following:

• Order Set: Mental Health Consult for Depression KNART

• Documentation Template Consult Request: Mental Health Consult for Depression KNART]

[Section Prompt: Suicide screen score]

<Obtain> Suicide screen score

[Section Prompt: Suicide screen results (positive or negative)]

<Obtain> Suicide screen results (positive or negative)

[Technical Note: Results are calculated as per the second section prompt in this section.]

[Section Prompt: For positive responses to the suicidal ideation question consider the following:]

[Technical Note: Upon completion of the PHQ2+I9, if the score is > 0 on the question about suicidal ideation, the user should be presented with links to the following:

• Documentation Template: Mental Health Suicide Risk Assessment KNART

• Order Set: Mental Health Positive Suicide Risk Screening KNART.]

[Technical Note: PHQ2+I9 responses and scores from this documentation template should be used to prepopulate the corresponding questions in the PHQ-9 if it is accessed in another KNART.]

[Technical Note: If the score is > 0 on the question “Thoughts that you would be better off dead or of hurting yourself in some way” Then display the following section prompt.]

[Section Prompt: This screen has resulted in a positive result for suicide risk on the primary screen (PHQ2+I9).

The secondary screen [Columbia-Suicide Severity Rating Scale (C-SSRS) screen] is required.]

[Technical Note: In accordance with policy in place at the time of implementation of this documentation template, the user completing the PHQ2+I9 screen may or may not be the person who is allowed to complete the

C-SSRS.]

[Technical Note: If the score = 0 on the question “Thoughts that you would be better off dead or of hurting yourself in some way” Then display the following section prompt:]

[Section Prompt: This screen has resulted in a negative result on the primary screen (PHQ2+I9) for suicide risk.

The secondary screen (C-SSRS screen) is not required.]

[Technical Note: A score weighting > 0 on the question “Thoughts that you would be better off dead or of hurting yourself in some way” constitutes a positive result for suicide risk on the primary screen (PHQ2+I9). If the primary screen (PHQ2+I9) is positive for suicide risk, then the secondary screen [Columbia-Suicide Severity Rating Scale (C-SSRS) screen] is required; if the primary screen (PHQ2+I9) is negative for suicide risk, then the secondary screen (C-SSRS screen) is optional and the following statement should be displayed to users: “The secondary screen (C-SSRS screen) is not required.” No restriction should be placed on the availability of the secondary screen (C-SSRS screen), but it should be required if the primary screen (PHQ2+I9) is positive for suicide risk and optional if the primary screen (PHQ2+I9) is negative for suicide risk.]

2.4. Secondary Screen [Columbia-Suicide Severity Rating Scale (C-SSRS) Screen]

[Technical Note: The secondary screen (C-SSRS screen) must be evaluated based on a step-wise analysis of question answers as described in the behaviors below. Adapted from Posner 2009 and Tri-Service Workflow 2017.]

[Section Selection Behavior: Select one response per question. Required.]

[Section Prompt: The timeframe for questions 1 through 5 is within the past month]

[Section Prompt: Wish to be dead: Person endorses thoughts about a wish to be dead or not alive anymore or wish to fall asleep and not wake up.]

1. [Section Prompt: Patient response to “Have you wished you were dead or wished you could go to sleep and not wake up?”]

☐ Yes

☐ No

[Section Prompt: Suicidal thoughts: General non-specific thoughts of wanting to end one’s life/die by suicide, “I’ve thought about killing myself” without general thoughts of ways to kill oneself/associated methods, intent, or plan.]

2. [Section Prompt: Patient response to “Have you actually had any thoughts of killing yourself?”]

☐ Yes

☐ No

[Technical Note: Skip to question 6 if answer to question 2 is “No.” Continue to question 3 if answer to question 2 is “Yes.”]

[Section Prompt: Suicidal thoughts with method (without specific plan or intent to act: Person endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. “I thought about taking an overdose, but I never made a specific plan as to when where or how I would actually do it....and I would never go through with it.”]

3. [Section Prompt: Patient response to “Have you been thinking about how you might do this?”]

☐ Yes

☐ No

[Section Prompt: Suicidal intent (without specific plan): Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to “I have the thoughts, but I definitely will not do anything about them.”]

4. [Section Prompt: Patient response to “have you had these thoughts and had some intention of acting on them?”]

☐ Yes

☐ No

[Section Prompt: Suicide intent with specific plan: Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.]

5. [Section Prompt: Patient response to “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?”]

☐ Yes

☐ No

[Section Prompt: The timeframe for question 6a is the patient’s entire lifetime]

6. [Section Prompt: Suicidal behavior question:]

6a. [Section Prompt: Patient response to “Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.”]

☐ Yes

☐ No

[Technical Note: Display question 6b if answer to question 6a is “Yes.”]

[Section Prompt: The timeframe for question 6b is the past 3 months]

6b. [Section Prompt: Patient response to “Were any of these in the past 3 months?”]

☐ Yes

☐ No

[Technical Note If: The answer to question 3, question 4, question 5, or question 6b is “Yes,” then display the following section prompt.]

[Section Prompt: This screen has resulted in a positive result on the C-SSRS and the VA Comprehensive Suicide Risk Assessment should be administered and used for risk factors and warning signs, protective factors, history of suicide attempts, and assessment and plan.]

[Clinical Note: Note that, as of January 2018, the VA Comprehensive Suicide Risk Assessment was being developed; when it becomes available, a link to it should be made available to users here if the screen is positive for suicide risk.]

<obtain> Additional information

[If: The answer to question 3, question 4, question 5, and question 6b are all “No,” then display the following section prompt.]

[Section Prompt: This screen has resulted in a negative result on the C-SSRS.]

[Technical Note: Provide link to Documentation Template-Consult Request: Mental Health - Consult for Depression KNART.]

[Link: Provide link to depression screen.]

[End Screening.]

2.5. Plan

[Begin Plan.]

☐ Continue routine ambulatory care

<Obtain> details

☐ Refer to mental health provider (routine)

☐ Refer to mental health provider now (same day)

[End Plan.]

2.6. Patient and Caregiver Education

[Begin Patient and Caregiver Education.]

[Technical Note: Allow users to set the default local VA facility telephone number in the space provided.]

[Section Prompt: Provide the following information to the Veteran: “We know that suicidal thoughts and urges can come on quick. If that happens for you, please reach out for some support by calling either the Veterans Crisis Line (1-800-273-TALK) or your local VA facility (___).”]

[Section Prompt: Access to Means Discussion:]

[Technical Note: Please provide a link to a brief education section about how to reduce access to means for committing suicide.]

[End Patient and Caregiver Education.]

[Technical Note: Upon completion of this documentation template, with a positive screen for suicide risk, activate the Order Set: Mental Health - Positive Suicide Risk Screening KNART.]

[End Documentation Template –Suicide Risk Assessment.]

Chapter 3. Order Set: Positive Suicide Risk Screening

[Begin Order Set: Positive Suicide Risk Screening.]

3.1. Knowledge Narrative

[Begin Knowledge Narrative.]

[See Clinical Context in Chapter 1.]

[Technical Note: This order set is intended for use by providers caring for patients in outpatient settings.]

[Link: Provide link to the VA Comprehensive Suicide Risk Assessment. Note that, as of January 2018, the VA Comprehensive Suicide Risk Assessment was being developed; when it becomes available, a link to it should be added here.]

[Link: Provide link to diagram "Algorithm A: Assessment and management of Risk for Suicide in Primary Care" on page 18 of https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf (VA/DoD 2013).]

[End Knowledge Narrative.]

3.2. Consults

[Begin Consults.]

☐ Refer to mental health provider (routine)

☐ Refer to mental health provider now (same day)

[End Consults.]

3.3. Follow up

[Begin Follow up.]

☐ Return to clinic in

<obtain> number of time intervals

☐ Days

☐ Weeks

☐ Month

<Obtain> details

[End Follow up.]

[End Order Set: Positive Suicide Risk Screening.]

Bibliography/Evidence

[Technical Note: Once the links for the new VA/screening guidelines/protocols are made available they will be inserted here.]

“Columbia Lighthouse Project. Columbia–Suicide Severity Rating Scale Screen Version – Recent. Columbia”.

Lighthouse Project website. Accessed October 2017. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare.

“Committee on the Assessment of the Readjustment Needs of Military Personnel, Veterans, and Their Families, Board on the Health of Select Populations, Institute of Medicine. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families”.

Washington (DC): National Academies Press (US);. Mar 2013.

https://www.ncbi.nlm.nih.gov/books/NBK206864/..

K Kroenke, RL Spitzer, and JB Williams. “The PHQ-9: validity of a brief depression severity measure”. J Gen Intern Med.. 2001. 16. 9. 606-613.

“Office of Mental Health and Suicide Prevention. Suicide Among Veterans and Other Americans 2001–2014”. .

U.S. Department of Veterans Affairs Mental Health website. Updated August 2017.

https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf.

Title 42 - Public Health. Condition of participation: Patient's rights. 71 FedRegist 71426, Dec. 8, 2006, as amended at 75 FedRegist 70844, Nov. 19, 2010; 77 FedRegist 29074, May 16, 2012. 42 CFR §482.13.

“Tri-Service Workflow (TSWF). TSWF-CORE AIM Form Version Jan-Apr 2017”. TSWF CORE Paper Backup Jan Apr 2017.pdf. Veterans Administration, materials provided in Mental Health-20170921T220116Z- 001.zip, September 21, 2017.

“U.S. Department of Veterans Affairs. VA Suicide Prevention Program Facts about Veteran Suicide. U.S.”.

Department of Veterans Affairs Office of Public and Intergovernmental Affairs website. Published July 2016.

https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_07061 6_1400.pdf.

“U.S. Department of Veterans Affairs; U.S. Department of Defense (DoD). VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. Version 1.0 – June 2013”. VA/DoD Clinical Practice Guidelines website. Published June 2013.

https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf.

“U.S. Department of Veterans Affairs; U.S. Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder”. VA/DoD Clinical Practice Guidelines website.

Published April 2016. Version 3.0 – 2016.

https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf.

Appendix A. Existing Sample VA Artifacts

The following images are referenced from the Portland VA Medical Center (VAMC). Their intent is to assist future coders/implementers with thinking about what their end results might look like. The content in these images does not match what is defined in this document.

Figure A.1. Reminder Dialog Template: Suicide Risk Assessment (Image 1 of 5)

Existing Sample VA Artifacts

Figure A.2. Reminder Dialog Template: Suicide Risk Assessment (Image 2 of 5)

Figure A.3. Reminder Dialog Template: Suicide Risk Assessment (Image 3 of 5)

Figure A.4. Reminder Dialog Template: Suicide Risk Assessment (Image 4 of 5)

Figure A.5. Reminder Dialog Template: Suicide Risk Assessment (Image 5 of 5)

Figure A.6. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Initial Screen Consult Note - Mental Health Impact Assessment (MHIA) (Image 1 of 6)

Figure A.7. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi

(MHIA) (Image 2 of 6)

Figure A.8. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi

(MHIA) (Image 3 of 6)

Figure A.9. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi

(MHIA) (Image 4 of 6)

Figure A.10. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi

(MHIA) (Image 5 of 6)

Figure A.11. Template: MHC Same Day Operation Enduring Freedom/Operation Iraqi

(MHIA) (Image 6 of 6)

Figure A.12 – Safety Plan (Image 1 of 20)

Figure A.13 – Safety Plan (Image 2 of 20)

Figure A.14 – Safety Plan (Image 3 of 20)

Figure A.15 – Safety Plan (Image 4 of 20)

Figure A.16 – Safety Plan (Image 5 of 20)

Figure A.17 – Safety Plan (Image 6 of 20)

Figure A.18 – Safety Plan (Image 7 of 20)

Figure A.19 – Safety Plan (Image 8 of 20)

Figure A.20 – Safety Plan (Image 9 of 20)

Figure A.21 – Safety Plan (Image 10 of 20)

Figure A.22 – Safety Plan (Image 11 of 20)

Figure A.23 – Safety Plan (Image 12 of 20)

Figure A.24 – Safety Plan (Image 13 of 20)

Figure A.25 – Safety Plan (Image 14 of 20)

Figure A.26 – Safety Plan (Image 15 of 20)

Figure A.27 – Safety Plan (Image 16 of 20)

Figure A.28 – Safety Plan (Image 17 of 20)

Figure A.29 – Safety Plan (Image 18 of 20)

Figure A.30 – Safety Plan (Image 19 of 20)

Figure A.31 – Safety Plan (Image 20 of 20)

A.1. Future Artifacts

Note: Documents 1-3, and Figure 12 are draft future artifacts provided by Dr. Catherine Barry/Dr. Jodie Trafton as of 2018-03-08; they are expected to be available 2018-2019. They have not been included in the clinical content above, as they are not yet available enterprise-wide. It is recommended that they either be integrated into the clinical content in this paper once they are available to users, or in separate KNART(s) that are developed accordingly.

A.1.1. Document 1 - DRAFT: VA Comprehensive Suicide Risk with options for New or Updating Existing Assessment

PLEASE NOTE: We plan to turn each of the responses into Health Factors, so they can be easily pulled from CDW and used for aggregate analysis

Is this a new assessment or an update to an existing assessment?

• New assessment

• Update to existing assessment

In what Setting is this Assessment Occurring? (Select only one response.) [Design note: originally we thought it best to remove this because it can be pulled from administrative data, but at the end of the template, we do have some specific strategies that should only display for MH Inpatient or MH Residential settings, so this may be useful to keep. Elizabeth G, I’m open to your suggestion here]

• Emergency Department

• Primary Care

• PCMHI

• Other Outpatient Med/Surg

• Inpatient Med/Surg

• Psychiatric Emergency Services

• MH Outpatient

• MH Inpatient

• MH Residential/Domiciliary

• Other [text box]

Suicidal Ideation

Does the Veteran have a history of or current suicidal ideation?

• No [Design note: if no, skip the rest of the questions in this Suicide Ideation section]

• Yes

How recently has the Veteran had thoughts of engaging in suicide-related behavior? (Select only one response.)

• Within the last 24 hours

• within the past 1 to 7 days

• within the past 8 to 30 days

• within the past 2 to 6 months

• within the past 7 to 12 months

• More than a year ago (13 or more months ago)

How frequent are/were the thoughts? (Select only one response.)

• Less than once a week

• Once a week

• 2-5 times a week

• Daily or almost daily

• Many times each day

Does/did the Veteran have a plan? (Select only one response.)

• No

• Yes – Describe [add text box]

Does the Veteran have access to lethal means to enact the plan described above? (Select only one response.)

• No

• Yes – Describe [add text box]

Does the Veteran have access to other lethal means? (Select only one response.)

• No

• Yes – Describe [add text box]

Does/did the Veteran have suicidal intent? (Select only one response.)

Suicidal intent: There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior.

• No

• Yes

History of Suicide Attempts

[Design note: If a ‘New Assessment’] Has the Veteran ever made a prior suicide attempt? (Select only one response.)

Suicide Attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

• No

• Yes

[Design note: If a ‘New Assessment’] If yes, how many suicide attempts has the Veteran made? (Select only one response.)

[drop down list with a selection for each number from 1 to 10; then a ‘11+’ response]

[Design note: If an ‘Update to existing Assessment’] Has the Veteran made a suicide attempt since the last documented VA Comprehensive Suicide Risk Assessment? (CSRA; xx/xx/xxxx) [Design note: pull in the date of the last CSRA here]

Suicide Attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

• No [Design note: If ‘no’, this section is complete]

• Yes

[Design note: If an ‘Update to existing Assessment’] If yes, how many suicide attempts has the Veteran made since the last CSRA? (Select only one response.)

[drop down list with a selection for each number from 1 to 10; then a ‘11+’ response]

When was the most recent attempt? (Select only one response.)

• Within the last 24 hours

• within the past 1 to 7 days

• within the past 8 to 30 days

• within the past 2 to 6 months

• within the past 7 to 12 months

• More than a year ago (13 or more months ago)

What was the method/were the methods used for this event? (Select all that apply.)

• Overdose (Select all that apply.)

[design note: expand to the items below only if Overdose is selected]

• Alcohol

• What type of alcohol did the Veteran drink? (Select all that apply)

• Beer

• Wine

• Liquor

• How many drinks did the Veteran have?

• Amphetamine/other psychostimulants

• How much did the Veteran take (e.g, # of pills, mg)?

• [add text box]

[Design note: I’m trying to determine if it makes sense to add option to select ‘mg’ or ‘# pills’ to ensure we know what measurement the responder means; also if there are other standard measures to offer as an option]

• Barbiturates

• How much did the Veteran take (e.g, # of pills, mg)?

• Benzodiazepine

• How much did the Veteran take (e.g, # of pills, mg)?

• Cocaine

• How much did the Veteran take (e.g, # of pills, mg)

• Fentanyl

• How much did the Veteran take (e.g, # of pills, mg)?

• Heroin

• How much did the Veteran take (e.g, # of pills, mg)?

• Lithium

• How much did the Veteran take (e.g, # of pills, mg)?

• Methadone

• How much did the Veteran take (e.g, # of pills, mg)?

• Pills (NOS)

• How much did the Veteran take (e.g, # of pills, mg)?

• Rx Meds

• How much did the Veteran take (e.g, # of pills, mg)?

• Suboxone, Subutex, Buprenorphine

• How much did the Veteran take (e.g, # of pills, mg)?

• Tylenol

• How much did the Veteran take (e.g, # of pills, mg)?

• Opioids other than listed above

• How much did the Veteran take (e.g, # of pills, mg)?

• Other (NOS), describe [add text box]

• How much did the Veteran take (e.g, # of pills, mg)?

• Physical Injury (Select all that apply.)

[design note: expand to the items below only if Physical Injury is selected]

• Attempted Drowning

• Where did this occur?

• Bathtub

• Bucket

• Swimming pool

• Natural body of water

• How far from shore or safety was the Veteran (in feet)?

(Round to nearest foot and enter as a whole number e.g. 1, 25, 52, 1000 etc.)

• [add text box] Feet

• Was the water?

• warm

• cold

• Can the Veteran swim?

• Yes

• No

• Other

• Electrocution

• What was used?

• Wall outlet

• Light socket

• Home electrical wire

• Utility wire

• Other [add text box]

• Where on the body?

• Wrists/arms

• Torso

• Legs

• Other [add text box]

• Ingest Poison/Chemical/Caustic Substance

• What type of substance was ingested?

• Rat poison

• Bleach

• Ammonia

• Other [add text box]

• How much was ingested (in mL or ounces)?

• Hanging

• What was used?

• String

• Rope

• Sheet

• Belt/strap

• Towel

• Other

• Jump from Height

• On what did the Veteran land?

• Solid ground

• Water

• Other [add text box]

• From how high did the Veteran jump (in feet)?

• [Add text box] Feet

• Jump in front of Auto/Train

• Was the Veteran struck or did the vehicle stop before hitting the Veteran?

• Struck

• Not struck

• Burnt Self

• Was caused the burn?

• Cigarette

• Lighter/match

• Oven/stove

• Curling iron/flat iron

• Candle

• Boiling water

• Other [add text box]

• Where on the body was burned?

• Wrists/arms

• Torso

• Legs

• Other [add text box]

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Stabbed/Cut Self

• Where on the body was cut?

• Head

• Neck

• Torso

• Arms

• Wrists

• Legs

• Other [add text box]

• What was used?

• Razor

• Kitchen knife

• Box cutter

• Scissors

• Other [add text box]

• How severe was the cut?

• Scratch

• Cut(s) with no tendon, artery or nerve damage

• Cut(s) with tendon, artery or nerve damage

• Were stitches required?

• If so, how many?

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Suffocation

• What was used?

• Carbon monoxide

• Plastic bag

• Pillow

• Other [add text box]

• Stopped required medical treatments or medications

• What did the Veteran stop?

• Needed medical treatment(s)

• Medication(s)

• Other [add text box]

• For how long was treatment/medication stopped (hours/days)?

• [add text box] [add option to select ‘hours’ or ‘days’]

• Other, describe [add text box]

• Firearm (Select all that apply.)

[design note: expand to the items below only if Gun is selected]

• What kind of firearm did the Veteran use?

• BB gun

• Pistol

• Rifle

• Shot gun

• Dart gun

• Other [add text box]

• Where did the Veteran shoot themselves? (Select all that apply)

• Head

• Chest

• Lower torso

• Limbs

• Other [add text box]

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Auto (Select all that apply.)

[design note: expand to the items below only if Auto is selected]

• Run into Object

• Run off Road

• Other (NOS), describe [add text box]

• Other method used (Select all that apply.)

[design note: expand to the items below only if Other is selected]

• Other (NOS), describe [add text box]

Obtain details of the attempt (extent of injuries, methods used, etc.)

• Not Provided

As a result of this attempt, was the Veteran taken to any of these places or did Veteran seek help at any of these places?

• Physician/nurse

• Without treatment or assessment and went home

• Medically treated and went home

• Medical treated and admitted to psychiatry unit

• Crisis outreach/after-hours team/mental health professional

• Police/wellness check

• Paramedics/ambulance/aid car

• Hospital emergency room

• Without assessment (e.g., talked to social worker or resident and went home)

• Without medical treatment

• Medically treated and went home

• Medically treated and admitted to psychiatry unit

• Inpatient, psychiatric unit

• For how many days?

• Was the visit voluntary?

• Yes, voluntary

• Voluntary, but threatened with legal commitment if not agreed to

• Legally detained on a 24-48 hour hold

• Legally detained on a 72+ hour hold

• Medically treated while on inpatient psychiatric unit, without going to emergency room

• While on psychiatric unit, went to emergency room for medical treatment and then returned to psychiatric unit

• Hospital medical unit, whether or not via emergency room, for observation (hours to overnight)

• Hospital medical unit, whether or not via emergency room, for required treatment

• For how many days?

• Intensive care unit, whether or not via emergency room or medical unit

• For how many days?

Was the suicide attempt interrupted? (Select only one response.)

• Yes, by self. Explain: [add text box]

• Yes, by other. Explain: [add text box]

Did the attempt result in injury? (Select only one response.)

• No

• Yes. Explain: [add text box]

When was the most lethal attempt? (Select only one response.)

• Within the last 24 hours

• within the past 1 to 7 days

• within the past 8 to 30 days

• within the past 2 to 6 months

• within the past 7 to 12 months

• More than a year ago (13 or more months ago)

What was the method/were the methods used for this event? (Select all that apply.)

• Overdose (Select all that apply.)

[design note: expand to the items below only if Overdose is selected]

• Alcohol

• What type of alcohol did the Veteran drink? (Select all that apply)

• Beer

• Wine

• Liquor

• How many drinks did the Veteran have?

• Amphetamine/other psychostimulants

• How much did the Veteran take (e.g, # of pills, mg)?

• [add text box]

[Design note: I’m trying to determine if it makes sense to add option to select ‘mg’ or ‘# pills’ to ensure we know what measurement the responder means; also if there are other standard measures to offer as an option]

• Barbiturates

• How much did the Veteran take (e.g, # of pills, mg)?

• Benzodiazepine

• How much did the Veteran take (e.g, # of pills, mg)?

• Cocaine

• How much did the Veteran take (e.g, # of pills, mg)

• Fentanyl

• How much did the Veteran take (e.g, # of pills, mg)?

• Heroin

• How much did the Veteran take (e.g, # of pills, mg)?

• Lithium

• How much did the Veteran take (e.g, # of pills, mg)?

• Methadone

• How much did the Veteran take (e.g, # of pills, mg)?

• Pills (NOS)

• How much did the Veteran take (e.g, # of pills, mg)?

• Rx Meds

• How much did the Veteran take (e.g, # of pills, mg)?

• Suboxone, Subutex, Buprenorphine

• How much did the Veteran take (e.g, # of pills, mg)?

• Tylenol

• How much did the Veteran take (e.g, # of pills, mg)?

• Opioids other than listed above

• How much did the Veteran take (e.g, # of pills, mg)?

• Other (NOS), describe [add text box]

• How much did the Veteran take (e.g, # of pills, mg)?

• Physical Injury (Select all that apply.)

[design note: expand to the items below only if Physical Injury is selected]

• Attempted Drowning

• Where did this occur?

• Bathtub

• Bucket

• Swimming pool

• Natural body of water

• How far from shore or safety was the Veteran (in feet)? (Round to nearest foot and enter as a whole number e.g. 1, 25, 52, 1000 etc.)

• [add text box] Feet

• Was the water?

• warm

• cold

• Can the Veteran swim?

• Yes

• No

• Other

• Electrocution

• What was used?

• Wall outlet

• Light socket

• Home electrical wire

• Utility wire

• Other [add text box]

• Where on the body?

• Wrists/arms

• Torso

• Legs

• Other [add text box]

• Ingest Poison/Chemical/Caustic Substance

• What type of substance was ingested?

• Rat poison

• Bleach

• Ammonia

• Other [add text box]

• How much was ingested (in mL or ounces)?

• Hanging

• What was used?

• String

• Rope

• Sheet

• Belt/strap

• Towel

• Other

• Jump from Height

• On what did the Veteran land?

• Solid ground

• Water

• Other [add text box]

• From how high did the Veteran jump (in feet)?

• [add text box] Feet

• Jump in front of Auto/Train

• Was the Veteran struck or did the vehicle stop before hitting the Veteran?

• Struck

• Not struck

• Burnt Self

• Was caused the burn?

• Cigarette

• Lighter/match

• Oven/stove

• Curling iron/flat iron

• Candle

• Boiling water

• Other [add text box]

• Where on the body was burned?

• Wrists/arms

• Torso

• Legs

• Other [add text box]

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Stabbed/Cut Self

• Where on the body was cut?

• Head

• Neck

• Torso

• Arms

• Wrists

• Legs

• Other [add text box]

• What was used?

• Razor

• Kitchen knife

• Box cutter

• Scissors

• Other [add text box]

• How severe was the cut?

• Scratch

• Cut(s) with no tendon, artery or nerve damage

• Cut(s) with tendon, artery or nerve damage

• Were stitches required?

• If so, how many?

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Suffocation

• What was used?

• Carbon monoxide

• Plastic bag

• Pillow

• Other [add text box]

• Stopped required medical treatments or medications

• What did the Veteran stop?

• Needed medical treatment(s)

• Medication(s)

• Other [add text box]

• For how long was treatment/medication stopped (hours/days)?

• [add text box] [add option to select ‘hours’ or ‘days’]

• Other, describe [add text box]

• Firearm (Select all that apply.)

[design note: expand to the items below only if Gun is selected]

• Attempted to induce police into shooting her/him [Design note: if selected this option by itself, do not show the other ‘firearm questions’]

• What kind of firearm did the Veteran use?

• BB gun

• Pistol

• Rifle

• Shot gun

• Dart gun

• Other [add text box]

• Where did the Veteran shoot themselves? (Select all that apply)

• Head

• Chest

• Lower torso

• Limbs

• Other [add text box]

• Were you able to verify the injuries by seeing scars?

• Yes

• No

• Auto (Select all that apply.)

[design note: expand to the items below only if Auto is selected]

• Run into Object

• Run off Road

• Other (NOS), describe [add text box]

• Other method used (Select all that apply.)

[design note: expand to the items below only if Other is selected]

• Other (NOS), describe [add text box]

Obtain details of the attempt (extent of injuries, methods used, etc.)

• Not Provided

As a result of this attempt, was the Veteran taken to any of these places or did Veteran seek help at any of these places?

• Physician/nurse

• Without treatment or assessment and went home

• Medically treated and went home

• Medical treated and admitted to psychiatry unit

• Crisis outreach/after-hours team/mental health professional

• Police/wellness check

• Paramedics/ambulance/aid car

• Hospital emergency room

• Without assessment (e.g., talked to social worker or resident and went home)

• Without medical treatment

• Medically treated and went home

• Medically treated and admitted to psychiatry unit

• Inpatient, psychiatric unit

• For how many days?

• Was the visit voluntary?

• Yes, voluntary

• Voluntary, but threatened with legal commitment if not agreed to

• Legally detained on a 24-48 hour hold

• Legally detained on a 72+ hour hold

• Medically treated while on inpatient psychiatric unit, without going to emergency room

• While on psychiatric unit, went to emergency room for medical treatment and then returned to psychiatric unit

• Hospital medical unit, whether or not via emergency room, for observation (hours to overnight)

• Hospital medical unit, whether or not via emergency room, for required treatment

• For how many days?

• Intensive care unit, whether or not via emergency room or medical unit

• For how many days?

Was the suicide attempt interrupted? (Select only one response.)

• No

• Yes, by self. Explain: [add text box]

• Yes, by other. Explain: [add text box]

Did the attempt result in injury? (Select only one response.)

• No

• Yes. Explain: [add text box]

Has the Veteran engaged in any preparatory behavior aside from behavior associated with any suicide attempts documented above?