ATTACHMENT 21 - Mental Health Suicide Risk Assessment.pdf

Mental Health: Suicide Risk Assessment Documentation Template

Documentation Template:

Conceptual Structure

Contract: VA118-16-D-1008, Task Order (TO): VA-118-16-F-1008-0007, CLIN0005AF

Department of Veterans Affairs (VA)

Knowledge Based Systems (KBS) Office of Informatics and Information Governance (OIIG)

Clinical Decision Support (CDS)

Publication date 06/18/2018

Version: 1.0

Mental Health: Suicide Risk Assessment Documentation Template:

Documentation Template: Conceptual Structure by Knowledge Based Systems (KBS), Office of Informatics and Information Governance (OIIG), and Clinical Decision Support (CDS)

Publication date 06/18/2018 Copyright © 2018 B3 Group, Inc.

Copyright © 2018 Cognitive Medical Systems, Inc.

B3 Group, Inc.

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Table of Contents Preface .............................................................................................................................. v Artifact Applicability .......................................................................................................... vi Models ............................................................................................................................ vii

1. External Data Definitions

2. Expression Definitions

3. Reason for Visit

4. Screening

5. Plan

6. Patient and Caregiver Education

7. Tabular List

8. Behavior Symbols A. References iii

List of Tables

1. Revision History ............................................................................................................. v

2. Clinical White Paper Contributors ...................................................................................... v

3. Artifact Identifier ............................................................................................................ v

4. Applicability Foci, Description and Codes .......................................................................... vi

5. Model References .......................................................................................................... vii

7.1. Terminology Versions

7.2. Terminology References

8.1. Group Organizational Behavior

8.2. Group Selection Behavior

8.3. Required Behavior

8.4. Precheck Behavior

8.5. Cardinality Behavior

8.6. Item Flags

8.7. Read Only Behavior

iv

Preface Table 1. Revision History

Date Life Cycle Event

June 18, 2018 Published

April 27, 2018 Published

April 27, 2018 Reviewed

April 6, 2018 Created

April 6, 2018 Pre-published

Table 2. Clinical White Paper Contributors

Name Role Affiliation

Rani Hoff, PhD

MPH

Reviewer Director, Northeast Program Evaluation Center Office of Mental Health and Suicide Prevention (10NC5) VA Central Office; Professor of Psychiatry Yale University School of Medicine

Bridget Matarazzo Reviewer Director of Clinical Services Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) Denver, CO 80220

Ira Katz Reviewer Senior Consultant for Mental Health Program Analysis

Edd Post Reviewer VA HSR&D

Table 3. Artifact Identifier

Domain Artifact ID Name urn:va.gov:kbs:knart:artifact:r1 7b21baf4-5b61-52a6-bcb2-fa7b88c0bdc7 B52 v

Artifact Applicability Table 4. Applicability Foci, Description and Codes

Focus Description Code System

Code Value Set Value Set Version

TargetUser Mental health providers; other physicians and nurses performing screening

N/A N/A

ClinicalFocus Patients identified as being at risk for suicide;

members of patient cohorts identified for suicide risk screening

N/A N/A

ClinicalVenue Mental Health Primary Care

N/A N/A

ClinicalVenue Outpatient SNOMED

CT

33022008 | Hospital-based outpatient department (environment)|

N/A N/A vi

Models Table 5. Model References

Referenced Model Description urn:solor.io:anf-model:1.0 VA Analysis Normal Form Model vii

Chapter 1. External Data Definitions No externalData expression definitions and no trigger definitions are present.

Chapter 2. Expression Definitions No expression definitions are present.

Chapter 3. Reason for Visit # prompt: Reason for patient encounter in the VA today response: String (Single)

Chapter 4. Screening Primary Screen - Patient Health Questionnaire – Plus (PHQ-plus)

Responses to the PHQ-plus are interpreted using the numbers following each response option below. Any score greater than 0 on the third question is a positive result for suicide risk. A score >=3 on the combined responses from the first 2 questions is considered a positive screen for depression.

# prompt: Acknowledge response: Boolean (Single)

Primary screen (PHQ-plus) is defined as questions 1, 2, and 9 from PHQ-9, and the PHQ-2 is defined as questions 1 and 2 from the PHQ-9

Components of this form below are adapted from (Kroenke 2001)

([APA 2018]) Patient Health Questionnaire (PHQ-9 & PHQ-2) link [https://www.apa.org/ pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx]

([Arrol 2010]) Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population link [https://dx.doi.org/10.1370%2Fafm.1139]

([Kroenke 2001]) The PHQ-9: validity of a brief depression severity measure. link [J Gen Intern Med.]

# prompt: Acknowledge response: Boolean (Single)

Ask the patient the following questions:

Over the past two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things?

✦ prompt: Select one.

response: Integer (Single) response range: EnumerationConstraint (List) item: Not at all (score =0) item: Several days (score =1) item: More than half the days (score =2) item: Nearly every day (score =3)

Feeling down, depressed, or hopeless?

✦ prompt: Select One response: Integer (Single) response range: EnumerationConstraint (List) item: Not at all (score =0) item: Several days (score =1) item: More than half the days (score =2) item: Nearly every day (score =3) responseBinding: Property ("feelingDown")

Thoughts that you would be better off dead or of hurting yourself in some way?

https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://dx.doi.org/10.1370%2Fafm.1139 https://dx.doi.org/10.1370%2Fafm.1139 J%20Gen%20Intern%20Med.

J%20Gen%20Intern%20Med.

J%20Gen%20Intern%20Med.

Screening

✦ prompt: Select one.

response: Integer (Single) response range: EnumerationConstraint (List) item: Not at all (score =0) item: Several days (score =1) item: More than half the days (score =2) item: Nearly every day (score =3) responseBinding: Property ("betterOffDead")

Condition:elm:Or (elm:Greater( elm:Property("betterOffDead" from: elm:ParameterRef(Responses)) elm:Literal()) elm:GreaterOrEqual( elm:Add( elm:Add( elm:Property("betterOffDead" from: elm:ParameterRef(Responses)) elm:Property("feelingDown" from:

elm:ParameterRef(Responses))) elm:Property("feelingDown" from:

elm:ParameterRef(Responses))) elm:Literal()))

PHQ-plus results for suicide risk

Calculate and display score prompt: PHQ-plus score for depressive symptoms response: Integer (Single) prompt: PHQ-plus result: indicate if negative or positive screen for depressive symptoms response: EntityName (Single) response range: EnumerationConstraint (List) item: Negative item: Positive responseBinding: Property ("phqPlusResult")

Condition:elm:Equal (elm:Property("phqPlusResult" from: elm:ParameterRef(Responses)) elm:Literal())

This screen has resulted in a positive result for suicide risk on the primary screen (PHQ-plus)

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

Represented Concepts: 3f4b945e-12b0-4733-a438-f07249f7a3a2 |Suicide risk assessment using Columbia-Suicide Severity Rating Scale (procedure)

# prompt: Acknowledge response: Boolean (Single)

Condition:elm:Equal (elm:Property("phqPlusResult" from: elm:ParameterRef(Responses)) elm:Literal())

This screen has resulted in a negative result for suicide risk on the primary screen (PHQ-plus)

The secondary screen [Columbia-Suicide Severity Rating Scale (C-SSRS) screen] is not required.

Represented Concepts: 3f4b945e-12b0-4733-a438-f07249f7a3a2 |Suicide risk assessment using Columbia-Suicide Severity Rating Scale (procedure)

# prompt: Acknowledge response: Boolean (Single)

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

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. Select one response per question.The timeframe for questions 1 through 5 is within the past month

The timeframe for questions 1 through 5 is within the past month

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.

✦ prompt: 1. Patient response to "Have you wished you were dead or wished you could go to sleep and not wake up?"

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No

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.

✦ prompt: 2. Patient response to: "Have you actually had any thoughts of killing yourself?"

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("thoughtOfKilling")

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."

Condition:elm:IsTrue (elm:Property("thoughtOfKilling" from: elm:ParameterRef(Responses)))

✦ prompt: 3. Patient response to "Have you been thinking about how you might do this?"

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("beenThinkingAboutHow")

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."

Condition:elm:IsTrue (elm:Property("thoughtOfKilling" from: elm:ParameterRef(Responses)))

✦ prompt: 4. Have you had these thoughts and had some intention of acting on them?

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("intentionOfActing")

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.

Condition:elm:IsTrue (elm:Property("thoughtOfKilling" from: elm:ParameterRef(Responses)))

✦ prompt: 5. Patient response to "have you had these thoughts and had some intention of acting on them? Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?"

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("hadThoughtsAndHadSomeIntentionOfActing")

The timeframe for question 6a is the patient’s entire lifetime

Suicidal behavior question:

✦ prompt: 6a. 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."

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("preparedToEndLife")

The timeframe for question 6b is the past 3 months

Condition:elm:IsTrue (elm:Property("preparedToEndLife" from:

elm:ParameterRef(Responses)))

✦ prompt: 6b. Were any of these in the past 3 months?

response: Boolean (Single) response range: EnumerationConstraint (List) item: Yes item: No responseBinding: Property ("preparedToEndLifeInPast3Months")

Condition:elm:AllTrue

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.

# prompt: Additional Information response: String (Single)

Condition:elm:Not (elm:AnyTrue())

This screen has resulted in a negative result on the C-SSRS.

# prompt: Acknowledge response: Boolean (Single)

Chapter 5. Plan # If the patient is to continue routine ambulatory care, please provide details.

prompt:

response: String (Single)

✪ prompt: Plan to refer to mental health provider (routine)?

response: Boolean (Single)

✪ prompt: Plan to refer to mental health provider now (same day)?

Chapter 6. Patient and Caregiver Education.

✦ Confirm: Provide the following information to the Veteran: We know that suicidal thoughts prompt: 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 (___).

Chapter 7. Tabular List Terminology Service Request (TSR) Mappings

Table 7.1. Terminology Versions

Name Identifer Version

SNOMED CT 2.16.840.1.113883.6.96 United States Edition 20180301

Table 7.2. Terminology References

System Code Display Texta Referencesb

SNOMED CT 33022008 |Hospital-based outpatient department (environment)|

Outpatient 1

SNOMED CT 3f4b945e-12b0-4733-a438-f07249f7a3a2 | Suicide risk assessment using Columbia-Suicide Severity Rating Scale (procedure)

Postcoordinated Expression 2 aIf a code is used multiple times in the KNART, only the display text of the first instance is shown.

bCount of the number of times the given code system and code pair is used in the KNART.

http:2.16.840.1.113883.6.96

Chapter 8. Behavior Symbols Table 8.1. Group Organizational Behavior

Symbol Name Definition

# Sentence Group A group of related alternative actions is a sentence group if the item referenced by the action is the same in all the actions, and each action simply constitutes a different variation on how to specify the details for that item. For example, two actions that could be in a SentenceGroup are "aspirin, 500 mg, 2 times per day" and "aspirin, 300 mg, 3 times per day". In both cases, aspirin is the item referenced by the action, and the two actions represent two different options for how aspirin might be ordered for the patient. Note that a SentenceGroup would almost always have an associated selection behavior of "AtMostOne", unless it's a required action, in which case, it would be "ExactlyOne".

# Logical Group A group with this behavior logically groups its sub-elements, and may be shown as a visual group to the end user, but it is not required to do so.

➤ Visual Group Any group marked with this behavior should be displayed as a visual group to the end user.

Table 8.2. Group Selection Behavior

Symbol Name Definition

# Any Any number of the items in the group may be chosen, from zero to all.

# All All the items in the group must be selected as a single unit.

# AllOrNone All the items in the group are meant to be chosen as a single unit: either all must be selected by the end user, or none may be selected.

# ExactlyOne The end user must choose one and only one of the selectable items in the group. The user may not choose none of the items in the group.

✪ AtMostOne The end user may choose zero or at most one of the items in the group.

❂ OneOrMore The end user must choose a minimum of one, and as many additional as desired.

Table 8.3. Required Behavior

Symbol Name Definition

✦ Must An action with this behavior must be included in the actions processed by the end user; the end user may not choose not to include this action.

✧ Could An action with this behavior may be included in the set of actions processed by the end user.

Behavior Symbols

Symbol Name Definition

MustUnlessDocumented An action with this behavior must be included in the set of actions processed by the end user, unless the end user provides documentation as to why the action was not included.

Table 8.4. Precheck Behavior

Symbol Name Definition

▲ Yes An action with this behavior is one of the most frequent actions that is, or should be, included by an end user, for the particular context in which the action occurs. The system displaying the action to the end user should consider "pre-checking" such an action as a convenience for the user.

# No An action with this behavior is one of the less frequent actions included by the end user, for the particular context in which the action occurs. The system displaying the actions to the end user would typically not "pre-check" such an action.

Table 8.5. Cardinality Behavior

Symbol Name Definition

◆ Single An action with this behavior may only be completed once.

❖ Multiple An action with this behavior may be repeated multiple times.

Table 8.6. Item Flags

Symbol Name Definition fillIn This item, in a list entry, allows the user to enter a fill in value that is not present in the set of presented choices.

Table 8.7. Read Only Behavior

Symbol Name Definition

# true For a particular action or action group, specifies whether the elements are read only.

Appendix A. References This appendix contains the list of related resources and supporting documents used in creating this

KNART.

List of References Related Resources [CCWP] Mental Health: Suicidality Clinical Content White Paper

[CSD] Mental Health: Suicide Risk Assessment Documentation Template Conceptual Structure Document

[KVRpt] Mental Health: Suicide Risk Assessment Documentation Template KNART Validation Report

Supporting Evidence [CLP 2017] Columbia–Suicide Severity Rating Scale Screen Version – Recent. Columbia Lighthouse Project website.

Accessed October 2017 (link [https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare])

[IOM 2013] 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. Available from https://www.ncbi.nlm.nih.gov/ books/NBK206864/. (link [https://www.ncbi.nlm.nih.gov/books/NBK206864/])

[Kroenke 2001] Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. (link [J Gen Intern Med.])

[OMHSP 2017] Office of Mental Health and Suicide Prevention. Suicide Among Veterans and Other Americans 2001–2014. U.S. Department of Veterans Affairs Mental Health website.

https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Updated August 2017. (link [https:// www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf])

[FedRegist 2012] 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. (link [https://www.federalregister.gov/])

[TSWF 2017] 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). (link [Mental Health-20170921T220116Z-001.zip September 21, 2017])

[VA 2016] 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. https://www.va.gov/opa/publications/factsheets/ Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf. Published July 2016. (link [https:// www.va.gov/opa/publications/factsheets/ Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf]) https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare https://www.ncbi.nlm.nih.gov/books/NBK206864/ https://www.ncbi.nlm.nih.gov/books/NBK206864/ J%20Gen%20Intern%20Med.

J%20Gen%20Intern%20Med.

https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf https://www.federalregister.gov/ https://www.federalregister.gov/ Mental%20Health-20170921T220116Z-001.zip%20September%2021,%202017 Mental%20Health-20170921T220116Z-001.zip%20September%2021,%202017 Mental%20Health-20170921T220116Z-001.zip%20September%2021,%202017 https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf https://www.va.gov/opa/publications/factsheets https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf http:https://www.ncbi.nlm.nih.gov

References

[VADOD 2013] U.S. Department of Veterans Affairs; U.S. Department of Defense (DoD0. 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. https://www.healthquality.va.gov/guidelines/MH/srb/ VADODCP_SuicideRisk_Full.pdf. Published June 2013. (link [https://www.healthquality.va.gov/guidelines/ MH/srb/VADODCP_SuicideRisk_Full.pdf])

[VADOD 2016] U.S. Department of Veterans Affairs; U.S. Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. Version 3.0 – 2016.

VA/DoD Clinical Practice Guidelines website. https://www.healthquality.va.gov/guidelines/MH/mdd/ VADoDMDDCPGFINAL82916.pdf. Published April 2016. (link [https://www.healthquality.va.gov/ guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf])

[APA 2018] American Psychological Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx (link [https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/ patient-health.aspx])

[Arrol 2010] Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., … Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population. Annals of Family Medicine, 8(4), 348–353. http://doi.org/10.1370/afm.1139 (link [https:// dx.doi.org/10.1370%2Fafm.1139]) https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://dx.doi.org/10.1370%2Fafm.1139 https://dx.doi.org/10.1370%2Fafm.1139 https://dx.doi.org/10.1370%2Fafm.1139 http://doi.org/10.1370/afm.1139 https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient https://www.healthquality.va.gov/guidelines/MH/mdd https://www.healthquality.va.gov/guidelines/MH/srb

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Tables

Rule Name Status Description

Rows Passed TR must be a child of Table, THead, TBody, or TFoot

TH and TD Passed TH and TD must be children of TR

Headers Passed Tables should have headers

Regularity Passed Tables must contain the same number of columns in each row and rows in each column

Summary Skipped Tables must have a summary

Lists

Rule Name Status Description

List items Passed LI must be a child of L

Lbl and LBody Passed Lbl and LBody must be children of LI

Headings

Rule Name Status Description

Appropriate nesting Skipped Appropriate nesting

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