D.10 MCM 658-116A-21 Suicide Assessment, Intervention, and Documentation.pdf

Department of Veterans Affairs VAMC MEMORANDUM 658-116A-21 VA Medical Center June 6, 2018 Salem, VA 24153 Suicide Assessment, Intervention, and

Documentation

SUICIDE ASSESSMENT, INTERVENTION, AND DOCUMENTATION

PURPOSE: Suicide and other forms of suicidal self-directed violence are a persistent and growing public health problem for America and its Veterans. Suicide currently ranks as the tenth most frequent cause of death in the United States, with one person dying from suicide approximately every 17 minutes. Veterans account for approximately 20- 22% of the deaths from suicide in this country and suicide rates for users of Veterans Health Administration (VHA) health care services are substantially higher than those of the general population. Unfortunately, at the present time there is no clear evidence that suicide can be accurately and reliably predicted, even among high-risk individuals.

Nevertheless, the prevalence and magnitude of this problem makes it essential that health care organizations implement processes for identifying, assessing, and managing patients who may be at risk for suicide or suicide attempts.

The purpose of this policy is to mitigate the risks of suicide among patients seen at the medical center and associated Community Based Outpatient Clinics (CBOC) by promoting evidence-based, recovery-oriented practices for the assessment, management, and treatment of suicide-related behaviors. More specifically, this policy delineates provider guidelines for assessing suicide risk, intervening with patients who exhibit heightened suicide potential, and documenting these assessment and intervention efforts in the patient’s medical record. Additional procedures for effectively managing suicide prevention efforts in the medical center and coordinating these efforts with Veterans Integrated Service Network (VISN) and Veterans Affairs Central Office (VACO) leadership are also outlined.

POLICY: A suicide assessment will be conducted for any patient with a primary diagnosis or primary complaint of an emotional or behavioral disorder. While a suicide assessment of patients with a secondary diagnosis or a secondary complaint of an emotional or behavioral disorder is not required, providers should carefully evaluate the need for a suicide assessment in these cases. Providers should also be alert to situations and events that may increase a patient’s risk for suicide and warrant a suicide assessment, even in the absence of a primary or secondary diagnosis or complaint of an emotional or behavioral disorder. These situations and events include, but are not limited to, significant psychosocial stressors (e.g., job loss, marital difficulties, and financial problems), a diagnosis of a serious medical illness, and a significant change in a psychiatric or medical condition.

In addition, suicide screenings will be completed during appointments in the primary care clinics and following any instance of a positive depression or posttraumatic stress disorder (PTSD) clinical reminder. The purpose of these screenings is to determine the need for a more thorough suicide assessment and/or immediate mental health referral. A positive suicide screening will result in a full suicide assessment.

D.10 MCM 658-116A-21 Suicide Assessment, Intervention, and Documentation 36C24621R0068

Salem, VA 24153 Suicide Assessment, Intervention, and

Documentation

Each suicide assessment and suicide screening will follow the procedures outlined in this policy to ensure that the relevant data is gathered and considered when making a judgment about a patient’s suicide potential. The outcomes from the suicide assessment and/or suicide screening will be documented in the patient’s medical record.

Patients judged to be at an increased risk for suicide will receive interventions that are consistent with the level of assessed risk and ensure that the patient’s immediate safety needs are addressed in the most appropriate treatment setting possible. Such patients and/or their significant others will be provided in writing with the appropriate telephone number(s) to use during working hours and other times in the event a crisis or emergency situation arises.

RESPONSIBILITIES:

a. The Chief, Mental Health Service Line (MHSL) has overall responsibility for establishing and communicating the policies and procedures pertaining to patient suicides and suicide attempts.

b. The Suicide Prevention Coordinator (SPC) is responsible for coordinating suicide prevention efforts throughout the medical center and associated CBOCs;

developing and/or implementing relevant training for medical center and CBOC staff; implementing the Behavioral Autopsy Program to review all completed suicides; identifying and working with local community agencies so that eligible Veterans may receive emergency support and referral to the medical center as soon as possible; ensuring that local or regional mental health hotlines are aware of the medical center as a resource in the event a Veteran should contact them and is in need of services.

c. The Chief, MHSL and the SPC, along with the Chief, Facilities Management Service (FMS), the Patient Safety Manager, the Chief, Veterans Affairs Police, and the Safety Specialist (as well as other designated staff who may be appointed to the facility’s mental health Environment of Care inspection team) will regularly review the inpatient psychiatric unit to ensure compliance with all mandated patient safety requirements and identify and address any safety- and security-related concerns with the unit’s design and physical structure.

d. All clinical service/service line chiefs are responsible for ensuring that pertinent providers under their supervision are aware of the contents of this policy and are competent in carrying out the designated procedures. In addition, service/service line chiefs are responsible for ensuring that all staff under their supervision review on an annual basis the procedures and guidelines outlined in Medical Center Memorandum (MCM) 658-116A-10, “Telephone Calls – Suicide or Homicide.”

This training must be documented in each employee’s Talent Management System (TMS) record and included as part of the employee’s annual competency plan.

e. Supervisors, in collaboration with the SPC, are responsible for ensuring that all designated employees complete additional annual training intended for staff whose job assignment increases the likelihood of telephone contact with potentially suicidal patients. The supervisor will document this training in the employee’s annual competency plan.

f. The providers designated in this policy are responsible for carrying out the required procedures to help ensure the safety of Veteran patients.

g. The SPC is responsible for tracking and trending all cases of suicidal self-directed violence (suicide and suicide attempts) by inpatients and outpatients. The SPC will inform the Patient Safety Manager, Risk Manager, and Peer Review Coordinator of all self-directed violence. The SPC will report suicidal self-directed violence to the Mental Health Behavioral Sciences Committee on a quarterly basis.

h. The Patient Safety Manager is responsible for convening, coordinating, and reporting the outcomes of Root Cause Analyses involving suicidal self-directed violence (suicide and suicide attempts).

ACTION:

a. Definitions.

(1) Suicide. Death caused by self-inflicted, injurious behavior with the intent to die as a result of the behavior.

(2) Suicide Attempt. A non-fatal, self-inflicted, potentially injurious behavior with the intent to die as a result of the behavior. A suicide attempt may occur with or without actual injury and may or may not be interrupted by self or others prior to any injury occurring.

(3) Suicidal Intent. There is past or present evidence (explicit and/or implicit) that at the time of the self-inflicted injury, the individual wished and intended to die and understood the probable consequences of his or her actions.

(4) Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

(5) Preparatory Behavior. Behavior that serves as preparation for engaging in self-directed violence but occurs prior to any potential for actual injury. This includes preparations beyond verbalizations or thoughts such as acquiring a method to commit suicide (e.g., buying a gun, collecting pills) or preparing for one’s own death by suicide (e.g., writing a suicide note, giving things away).

(6) Suicidal Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence (implicit and/or explicit) of suicidal intent. Suicidal self-directed violence includes both suicide and suicide attempts.

(7) Non-Suicidal Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself; however, there is no evidence (implicit and/or explicit) of suicidal intent. Rather, a person may engage in non-suicidal self-directed violence in order to attain some other desired outcome (e.g., to seek help, regulate negative mood, punish others, or receive attention). Non-suicidal self-directed violence may occur with or without injury, may or may not be interrupted by self or others prior to any injury occurring, and may have the potential to be fatal.

(8) Undetermined Self-Directed Violence. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself; however, suicidal intent is unclear based upon the available evidence. For example, the person’s condition (e.g., unconscious, intoxicated, acutely psychotic, deceased) renders him or her unable to acknowledge the intent to die, or the person is reluctant to admit the intent to die for other or unknown reasons. Undetermined self-directed violence may occur with or without injury, may or may not be interrupted by self or others prior to any injury occurring, and may have the potential to be fatal.

(9) Suicidal Ideation. Thoughts of engaging in suicide-related behavior. Suicidal ideation may occur with or without suicidal intent, or the person’s suicidal intent may be undetermined.

(10) Non-Suicidal Self-Directed Violence Ideation. Self-reported thoughts regarding a desire to engage in self-inflicted, potentially injurious behavior without evidence of suicidal intent. For example, a person may engage in and report non-suicidal self-directed violence ideation in order to attain some other desired outcome (e.g., to seek help, regulate negative mood, punish others, or receive attention).

(11) Suicide Screening. A relatively brief evaluation consisting of selected screening questions that allows the provider to determine whether a more thorough suicide assessment and/or immediate mental health intervention is warranted (see section 4.b.).

(12) Suicide Assessment. A formal clinical evaluation process designed to elicit the necessary information to make a reasonable determination about a person’s current risk for self-harm. For purposes of this policy, a suicide assessment consists of a number of required components that must be addressed and documented in the patient’s medical record (see section 4.c.).

(13) Low Suicide Risk. A patient judged not to be at significant risk for self-harm.

(14) Moderate Suicide Risk. A patient judged to be at an increased risk of suicide, but not acutely dangerous to self.

(15) High Suicide Risk. A patient judged to be at acute risk for self-harm.

(16) Mental Health Service Line (MHSL) Provider. Providers who are organizationally aligned with the MHSL and assigned to either a MHSL or non- MHSL (e.g., Primary Care) program area, as well as providers who are not organizationally aligned with the MHSL (e.g., social worker, nurse practitioner), but are assigned to a MHSL program area.

b. Suicide Screening.

(1) A suicide screening will be completed on the same day following any instance of a positive depression or PTSD clinical reminder. The suicide screening for positive depression and PTSD clinical reminders consists of the following questions from the VHA Suicide Risk Assessment Guide:

Are you feeling hopeless about the present/future?

Have you had thoughts about taking your life?

When did you have these thoughts and do you plan to take your life?

Have you ever had a suicide attempt?

A positive suicide screening (i.e., answering affirmatively to any of the four questions) will result in a full suicide assessment during the same clinic visit.

(2) Patients seen in the primary care clinics will receive a suicide screening during each clinic visit. The suicide screening may be waived if the patient has received a suicide screening in primary care within the preceding 14 days. The suicide screening will be completed as a part of the nursing intake assessment and the results included in the nursing intake note. An affirmative answer to the primary care suicide screening question, “During the past two weeks have you had urges to harm yourself or anyone else?” will result in a full suicide assessment during the same clinic visit.

(3) Patients seen in the outpatient sub-specialty medical clinics (e.g., Pain Clinic, Orthopedic Clinic, and Oncology Clinic) who indicate, either verbally or behaviorally, that they may be at risk for suicidal behaviors will be evaluated by a mental health professional during their clinic visit. The medical provider will call or page the designated mental health staff for immediate evaluation of suicide risk. The mental health provider will screen the patient to evaluate suicide risk and, if indicated (i.e., a positive response to any suicide screening question), will conduct a suicide assessment.

(4) Patients hospitalized on a medicine or surgery unit who are at a heightened risk for suicide but are not medically stable for transfer to acute care psychiatry will be evaluated by the liaison psychiatrist. The liaison psychiatrist can be accessed via electronic consult; after administrative hours, the psychiatrist on-call should be contacted. A psychiatric consultation should involve verbal physician-to-physician contact in addition to the electronic consult.

(5) In situations where a patient is seen at the medical center by a MHSL provider and the sole purpose of the visit is for the provider to impart information or provide education (versus to provide clinical services), the provider must conduct a suicide screening. If indicated by the screening outcome or warranted by the patient’s presentation, the provider should immediately conduct a suicide assessment and provide whatever clinical interventions are indicated.

(6) Unless there is an indication of clinical need, Veterans who are seen during outreach activities in the community do not require a suicide screening or suicide assessment.

c. Suicide Assessment.

(1) For assessments done in mental health at the time of admission, in the emergency department if sent out or admitted, prior to discharge, or whenever there is a major change in the condition, a full assessment must be done. For screening/evaluation/assessment in non-mental health areas, it is sufficient to do the reminder templated suicide risk evaluation, which includes three initial questions. If any of those are positive, then the entire assessment must be done.

The approved suicide assessment format is provided in the Computerized Patient Record System (CPRS) as a note template entitled “Suicide Assessment.” All elements of this assessment must be completed, including the suicide screening items, other current risk factors, social/demographic risk factors, current psychosocial stressors/recent losses, and protective factors. In addition, the assessment must include a rating of suicide risk (low, moderate, high) in which the provider integrates all available information and makes a clinical judgment about the patient’s current risk of suicidal behavior. The provider must also provide a plan of care that ensures the patient’s immediate safety and provides treatment in an appropriate care setting that is consistent with the assessed level of suicide risk. All patients who are judged to be at risk for self-harm and/or their significant others must be provided in writing with the appropriate telephone number(s) to use during working hours and other times in the event a crisis or emergency situation arises.

(2) Where there is an imminent risk of suicide, the patient must not be left alone and a psychiatric consult or admission should be pursued. When necessary and appropriate, emergency detainment and commitment procedures may also be implemented (see MCM 658-116A-09, “Detainment/Commitment Procedures”).

In situations where there is a heightened risk of suicide but no imminent risk of self-harm, the provider may take alternative actions such as referral for mental health treatment, informing and involving someone close to the patient, limiting the patient’s access to a means of suicide (e.g., removing weapons from the home), and increasing contact with the patient in order to help him/her through the immediate crisis.

(3) A suicide assessment may be conducted at any point in a patient’s clinical care; however, a suicide assessment must be conducted with any patient who has a primary diagnosis or primary complaint of an emotional or behavioral disorder at the time of the first diagnosis of this problem or presentation of this complaint or whenever a patient with such a diagnosis or complaint presents to the Emergency Department (ED). In this latter instance, a suicide assessment must be completed only if the patient presents to the ED with a psychiatric issue or complaint or presents with an emergent physical issue that might reasonably be expected to impact or exacerbate existing psychiatric problems (e.g., a patient with military sexual trauma who has been assaulted).

(4) In addition, for patients seen by MHSL providers for clinical services (versus services that are exclusively informational or educational in nature), suicide assessments must also be conducted (1) when a patient is seen for the first time as an outpatient; (2) as part of the History and Physical (H&P) examination at the time of admission to inpatient psychiatry or the Substance Abuse Residential Rehabilitation Treatment Program (SARRTP); (3) within 48 hours prior to discharge from inpatient psychiatry or the SARRTP; and (4) whenever the patient has had suicide identified as a clinically relevant issue (e.g., a history of suicide attempts, recently expressed suicidal ideation).

(5) There are two exceptions to the requirement that all elements of the suicide assessment be completed:

If, prior to completion of the suicide assessment, it is determined that the patient will be admitted to an inpatient psychiatry unit or referred immediately to a mental health professional, it is not necessary to complete the entire suicide assessment. A brief progress note should be entered into the patient’s medical record noting the decision to transfer the patient to a higher level of care along with any relevant findings from those suicide assessment elements that were completed. The complete suicide assessment will then be conducted by the provider at the higher level of care.

If a complete suicide assessment has been conducted during a current inpatient stay, it is not necessary to repeat the historical and unchanged elements for the suicide assessment that is conducted within 48 hours prior to the patient’s discharge.

(6) Within the MHSL (including MHSL staff assigned to non-MHSL programs and non-MHSL staff assigned to MHSL programs), suicide assessments will be conducted by MD/DO, PhD/PsyD, MSW, NP, and PA staff. The guidelines in this policy will also apply to other MHSL clinical staff members who perform patient assessments under the direction, guidance, or supervision of MD/DO or PhD/PsyD staff (e.g., rehabilitation technician, social science program specialist, vocational rehabilitation specialist) and to all psychiatry residents, psychology fellows, psychology interns, and psychology practicum students as well as social work students assigned to MHSL program areas.

(7) In other clinical service/service lines, suicide assessments will be conducted by MD/DO, MSW, NP, and PA staff. The guidelines in this policy will also apply to all psychiatry residents, psychology fellows, psychology interns, psychology practicum students, and social work students working in non-mental health areas of the medical center.

(8) Additionally, the only RN-level nursing staff members who have medical center approval to complete suicide assessments are the RN case managers working in the Mental Health Intensive Case Management (MHICM) Program. It is not considered to be within the scope of practice for RN-level nursing staff in other areas of the medical center to complete suicide assessments.

d. Documentation.

(1) A suicide assessment should be documented in the patient’s medical record using the progress note template entitled “Suicide Assessment.” This note template can be accessed in CPRS by selecting “Suicide Assessment” note title before entering a new progress note in the progress notes section of CPRS.

(2) Suicide screenings and assessments should reflect an active assessment process in which the provider asks specific questions about suicide and elicits relevant responses from the patient.

(3) In situations where a provider is continuing to see a patient after conducting a suicide assessment and ruling out suicide as a relevant issue, it is an acceptable practice to document a passive suicide assessment in a progress note (e.g., “no evidence of suicidal ideation,” “no suicidal ideation was expressed,” “not suicidal”); however, the provider should continue to be alert for any changes in the patient’s psychiatric and psychosocial status that would signal the need for a more thorough and more active suicide assessment. Such changes include, but are not limited to, new or worsening psychiatric symptoms, significant psychosocial stressors (e.g., job loss, marital difficulties, and financial problems), and a diagnosis of a serious medical condition.

e. Reassessment.

(1) Once a patient has been judged to be at a heightened risk for self-harm, reassessment of suicide potential must occur on a regular basis. The frequency of reassessment will be determined by the level of risk presented by the patient, including careful consideration of any factors that might imply an increase in the patient’s potential for self-harm (e.g., increased depression, recent stressors).

The higher the level of risk, the more frequently the patient should be reassessed.

As with the initial assessment, all reassessments must be thoroughly documented in the patient’s medical record.

(2) In those instances when a patient is failing to improve, is exhibiting worsening depressive symptoms, or is making repeated or unscheduled visits to the clinic or ED, interventions such as offering inpatient hospitalization and contacting family members to obtain additional information may be warranted.

f. Patient Record Flags.

(1) Patient Record Flags (PRF) may be used for patients who are at a high risk for suicide as a means of enhancing patient safety and ensuring that providers can incorporate the patient’s risk status into their treatment decisions. The goal is to identify high-risk patients as early as possible in order to provide access to enhanced care and services that may result in decreased suicide risk.

(2) The use of a PRF is intended to address short-term clinical safety concerns and is strictly limited to information that is essential for the delivery of appropriate health care. It is important to ensure that a PRF is used only for those patients who are at a high risk for suicide and only for the duration of the increased risk.

The PRF should be removed as soon as it is no longer clinically indicated. This is especially important to minimize the risk of undue stigmatization for the patient and to maintain the value of the PRF system as an alert to a short-term clinical safety concern.

(3) Patients who are identified as being at a high risk for suicide will receive enhanced follow-up care that meets VHA standards for such patients. In particular, the patient’s provider should consider frequent follow-up appointments and, whenever possible, involve the patient’s significant others in the care planning process and enlist their assistance to limit the patient’s access to possible means of self-harm. In addition, the Suicide Prevention Case Manager will assist with treatment coordination and monitoring of care.

(4) The presence of a High Risk for Suicide PRF does not require the patient to check in with the Veterans Affairs Police prior to scheduled appointments nor does it require staff members to notify the Veterans Affairs Police when the patient is on medical center grounds. Similarly, patients should not be denied access to medical center treatment programs or resources solely on the basis of having a High Risk for Suicide PRF in their medical record.

(5) A patient may be judged to be at a high risk for suicide and an appropriate candidate for a PRF for any number of reasons. In all cases, however, the use of a PRF is a clinical decision made after appropriate evaluation of relevant risk factors (e.g., history of past suicide attempts, recent discharge from an inpatient mental health unit), protective factors, and the presence or absence of suicide warning signs. The following, although not exhaustive, provides some general guidelines for the types of patients who may be appropriate for a PRF:

Patients for whom there has been a recent verified report of a suicide attempt.

Patients with current serious suicidal ideation that requires an immediate change in their treatment plan (e.g., patients with suicidal ideation who are admitted to an inpatient mental health facility).

Patients with clinical indicators for suicide risk such as serious suicidal ideation, threats of self-harm or suicide, identifying specific ways to commit suicide, seeking access to the necessary means to commit suicide (e.g., pills, weapons), and uncharacteristically talking or writing about death, dying, or suicide.

Patients who have a suicide behavior event reported in the Suicide Prevention Application Network (SPAN) database.

Patients who call the national Veterans Crisis Line or other available help lines expressing thoughts or intentions of suicide.

Patients with a past history of suicide attempts or behaviors who are now experiencing a crisis in their lives.

(6) A patient who is deemed by the provider or treatment team to be an appropriate candidate for a PRF may be referred via the "MH OUTPT Suicide Risk Management” or the “MH INPT Suicide Risk Management" consults in CPRS. The referral should only occur following a face-to-face mental health evaluation of the patient by a mental health provider.

(7) The SPC is responsible for reviewing all referrals and for consulting with the patient's treatment team to determine whether placement of a PRF is clinically indicated. Once a determination has been made that the patient is at a high risk for suicide, he/she will be placed on the facility high-risk list, and a High Risk for Suicide PRF and a progress note will be placed in the patient’s medical record.

(8) Patients who are referred for a PRF while hospitalized on acute care psychiatry will have a safety plan documented in the medical record using the "Safety Plan" progress note template. The safety plan will be completed by a member of the inpatient treatment team during the patient's hospitalization once the treatment team has determined the patient is psychiatrically stable and able to meaningfully engage in safety planning. The patient will be provided with a copy of the completed safety plan prior to discharge. The SPC is responsible for monitoring compliance with safety planning protocol.

(9) In situations where a patient is admitted to acute care psychiatry from another medical center, the inpatient treatment team at the Salem VAMC will make a determination about the need for a PRF based upon its evaluation of the patient during hospitalization. The referring facility should not initiate a PRF immediately prior to transfer and admission.

(10) In situations where a patient is admitted to acute care psychiatry from another medical center with an active, pre-existing High Risk for Suicide PRF, Salem VAMC’s SPC is responsible for ensuring the high-risk care management protocol is followed.

(11) A patient from another medical center who is admitted to acute care psychiatry with an active, pre-existing PRF for suicide risk or referred by the inpatient treatment team for a PRF will have a safety plan completed prior to discharge. The SPC, or designee, will notify the SPC at the referring facility prior to the patient's discharge in order to facilitate the coordination of outpatient high-risk follow-up care. Once the Veteran engages in outpatient care at the referring facility, the SPC will transfer ownership of the PRF from Salem VAMC to the referring facility where the Veteran is receiving care. The SPC, or designee, will notify the SPC at the referring facility to alert them regarding the transfer of ownership of the High Risk for Suicide PRF to their facility. This PRF transfer protocol is also followed in situations where a Veteran with an active High Risk for Suicide PRF transfers his/her health care to another VAMC as an outpatient (i.e.

Veteran relocates outside Salem VAMC catchment area).

(12) For patients referred for a PRF as an outpatient, the outpatient mental health provider is responsible for completing a safety plan and documenting the plan using the "Safety Plan" progress note template. The safety plan will be completed during the same visit in which the patient is identified as high risk and referred for a PRF. The outpatient provider will provide the patient with a copy of the completed safety plan.

(13) In all cases, safety plans should be developed collaboratively between the provider and the patient. If a patient is unwilling to participate in safety planning, the provider will document this in a progress note in the patient’s medical record and attempt to complete the safety plan at the next visit. For outpatients, the next visit should be scheduled within seven (7) days. For inpatients, safety planning should be attempted again during the first outpatient mental health appointment scheduled within seven (7) days of discharge.

(14) Should a patient disagree with placement of a PRF (or request removal of a PRF that has already been placed), the SPC will consult with the Chief of Staff who will make the final determination about the PRF.

(15) Each PRF will be re-evaluated at least every 90 days to ensure the flag is promptly removed when the high-risk status is resolved. The Suicide Risk Management Committee will meet monthly and, in consultation with the patient’s provider and/or Mental Health Treatment Coordinator (MHTC), will determine whether to continue or remove a PRF. The following criteria will warrant removal of a PRF for suicide risk:

The patient’s high-risk status has successfully resolved.

The patient has decided to receive care from providers in the community and is no longer followed at this medical center.

The SPC and mental health provider have been unable to contact the patient by telephone or mail for a period of 30 days from the date of the high-risk referral and there are no indications of safety concerns that would warrant a wellness check by police.

(16) Once it is determined that a patient no longer meets the criteria for a PRF, the PRF will be removed from the patient’s medical record; however, the patient can be re-considered for a PRF and high-risk follow-up in the future if a provider determines that the patient is once again at a high risk for suicide.

(17) Staff should remain aware that the absence of a high risk for suicide PRF in a patient’s medical record does not preclude the possibility of suicide potential or a suicide attempt. All staff should recognize that any patient may be at risk for suicide regardless of the flag status.

g. Suicide Behavior Report.

(1) The Suicide Behavior Report (SBR) will be used as the sole mechanism for reporting suicidal or undetermined self-directed violence and is available in CPRS as a progress note template entitled “Suicide Behavior Report.” Non-suicidal self-directed violence behaviors do not need to be reported using the SBR.

(2) The SBR will be completed by any clinical medical center staff person whenever they become aware that a patient has engaged in any of the following self-directed violence behaviors: preparatory behavior, undetermined self-directed violence, or suicidal self-directed violence (suicide attempt or suicide).

(3) The SPC may complete this report when a referral is received from the Veterans Crisis Line (or from another source such as a community facility) indicating that a patient has engaged in preparatory behavior, undetermined self-directed violence, or suicidal self-directed violence (suicide attempt or suicide).

(4) Completion of the SBR may be an indication that a PRF needs to be placed in the patient’s medical record, but it is not the sole criterion, nor is it necessary for the placement of a PRF for suicide risk.

(5) The SPC is responsible for establishing processes to ensure that the Patient Safety Manager, Risk Manager, and External Peer Review Program (EPRP) Coordinator are aware of all patient suicidal self-directed violence behaviors (suicide attempts and suicides).

(6) Decisions regarding the need for a Behavioral Autopsy, Root Cause Analysis, Aggregate Review, Issue Brief, and/or Quality Peer Review for reports of suicidal self-directed violence behaviors (suicide attempts and suicides) will be made according to current VHA guidelines (see the Deputy Under Secretary for Health for Operations and Management Memorandum, "Suicide and Suicide Attempt Reporting Requirements", dated April 12, 2010, and the Deputy Under Secretary for Health for Operations and Management Memorandum, “ Behavioral Autopsy Program Implementation”, dated December 11, 2012).

h. Veterans Crisis Line.

(1) The SPC will be notified of referrals from the Veterans Crisis Line via e-mail, voice mail, and a web-based crisis line application. Referrals received during regular administrative hours (Monday through Friday, 7:45 a.m. – 4:30 p.m.) are followed up within 24 business hours (one business day) of notification. Referrals made after administrative hours, weekends, and holidays, are received by the SPC the next business day and follow-up is provided within 24 business hours (one business day).

(2) Upon receipt of the referral notification, the SPC, or designee, will review the crisis line call details documented by the crisis line responder on the web-based crisis line application.

(3) For calls that required a rescue to be initiated by the crisis line responder, the SPC, or designee, will follow up with the Veterans Affairs Police and/or local community police department or other emergency mental health services to determine the outcome of the rescue. If the Veteran was unable to be located by the police or if the Veteran was determined to not be a danger to self or others following evaluation by police and/or emergency mental health services, attempts will be made to contact the Veteran by telephone and, if indicated, a wellness check by local police will be initiated by the SPC, or designee. If the Veteran was taken to a community mental health facility, the SPC, or designee, will make efforts to establish contact with the Veteran following discharge to assist with care coordination and evaluate the Veteran for placement on the facility high-risk list.

If the Veteran is transferred from a community mental health facility to the medical center’s acute care psychiatry unit, the SPC, or designee, will follow up with the Veteran's inpatient treatment team to determine if a high-risk referral is clinically indicated.

(4) For non-emergent referrals, the SPC, or designee, will ensure that attempts are made to contact the Veteran or family member who called the crisis line. If the Veteran has a known mental health provider, the SPC, or designee, will inform the provider of the Veteran's call to the crisis line and ask the provider to follow up with the Veteran within 24 business hours and advise the SPC, or designee, of the outcome. If the Veteran does not have a mental health provider, their mental health provider is not available to provide follow-up, or they are not enrolled in services, the SPC, or designee, will provide the necessary follow-up contact.

(5) A total of three (3) attempts will be made to reach the Veteran by telephone, and each attempt will be documented in the Veteran’s medical record. If a message is left for the Veteran, either on voice mail or with another person, the message will include only the Veteran’s name, telephone number, and a request for a return call. No health care information, including information from the crisis line referral, should be released without the Veteran's permission. The only exceptions are instances when it is determined that there is a concern for the Veteran's immediate safety, and in those situations, the information released should be limited to that which is absolutely necessary to assist with crisis management.

(6) For Veterans who cannot be reached by telephone, a letter will be mailed in an effort to engage the Veteran with services and offer assistance with care coordination.

(7) If the Veteran is reached by telephone, the SPC, or designee, will evaluate the Veteran's needs and provide assistance as needed and appropriate in addressing care-related concerns. If during contact with the Veteran, there is any indication that the Veteran is in need of emergency medical attention or that the Veteran is an immediate danger to self or others, the Veterans Affairs Police will be contacted and a wellness check initiated.

(8) Once follow-up has been completed, the SPC, or designee, will complete the appropriate documentation in the patient’s medical record and on the web-based crisis line application.

i. Management of Suicidal Crises in Community Based Outpatient Clinics.

(1) If there are immediate concerns about a patient’s risk of harm to self or others, a staff person should call 911 or the local police department. The patient should not be left unattended or allowed to leave the clinic. Staff should not attempt to subdue or detain a patient who is violent, hostile, or threatening;

however, if there are no safety concerns for staff, a staff person should remain with the patient until emergency assistance arrives. When police arrive at the CBOC, staff should report all relevant observed behavior, including statements made by the patient and any information provided by the patient’s family members.

(2) If there is not an immediate concern regarding the patient’s risk of harm to self or others, staff should document the suicide assessment and safety plan (involving the patient’s family whenever possible) and advise the patient to go to nearest ED for further evaluation and treatment.

(3) All such incidents occurring at a CBOC should be reported immediately to the SPC, or designee.

j. Management of High-Risk Patients and Veterans Crisis Line Referrals in Community Based Outpatient Clinics.

(1) All processes and procedures outlined in this policy should be followed by CBOC providers to ensure compliance with local, VISN, and national Suicide Prevention Program requirements.

(2) Providers at the CBOC sites will be notified of high-risk patients and crisis line referrals by the SPC or the Suicide Prevention Case Manager.

(3) Appropriate follow/up for these patients will be provided by the CBOC providers. The SPC and Suicide Prevention Case Manager will remain available on a consultative basis to assist with care coordination as needed.

k. No-Show Procedures.

(1) Whenever a patient misses a scheduled mental health or substance abuse treatment appointment, staff must attempt to contact that patient.

(2) In most cases, follow-up can be completed by any staff member; however, if the patient is on the high-risk list (i.e., has a PRF), a qualified mental health provider must make the contact.

(3) Attempts to follow-up on patients who miss a scheduled appointment will be by telephone in most cases. In the event a patient does not have a telephone, follow-up may be done via registered mail.

(4) At least three attempts should be made to reach the Veteran, and these attempts must be documented in the patient’s medical record.

(5) If a message is left for the patient, either on voice mail or with another person, the message should include only a request for a return call from the patient. No health care information should be released without the patient's permission. The only exception is when there is a concern for the patient's immediate safety. In those situations, the information released should be limited to what is absolutely necessary to assist with crisis management.

(6) Upon contacting the patient, if there is any indication that emergency medical attention is needed or that the patient represents an immediate danger to self or others, the Veterans Affairs Police should be contacted immediately and a wellness check initiated.

(7) If contact is unsuccessful for a high-risk patient after three attempts, the SPC will collaborate with the treatment provider(s) to determine the next appropriate step, using the pre-developed Safety Plan if possible. Contacting Veterans Affairs Police or local law enforcement for assistance is recommended when risk of harm is deemed to be imminent.

l. Police Assistance in Crisis Management.

(1) The Veterans Affairs Police should be notified immediately at extension 2224 to report any of the following potentially suicide-related incidents:

In the event a staff person speaks to a Veteran by telephone and determines that the Veteran is in need of emergency medical attention (e.g., the Veteran has overdosed or another physical injury has occurred) or represents an immediate danger to self or others, Veterans Affairs Police should be contacted to request a wellness check per the protocol outlined in MCM 658-116A-10, "Telephone

Calls – Suicide or Homicide.” In these situations, health care information may be released to the Veterans Affairs Police without the patient’s permission to assist the police with crisis management.

Should it be determined during an appointment at the medical center that a patient poses an immediate danger to self or others and the provider requires assistance to ensure safe escort to the ED, the Veterans Affairs Police should be notified and asked to accompany the patient to the ED for evaluation for possible commitment;

however, the Veterans Affairs Police can only accompany the patient to the ED if a medical center psychiatrist has indicated that he/she has contacted the relevant community agency to initiate a Temporary Detention Order (TDO).

The Veterans Affairs Police should be notified if a patient or other individual on medical center grounds is behaving in a violent, hostile, or threatening manner or has a weapon or other object intended to be used as a weapon.

(2) In the event a report is made by telephone to medical center staff by someone other than a Veteran (e.g., friend, family member) that a Veteran is suicidal/homicidal, the staff member should ask to speak directly to the Veteran to verify this information. If the staff member is unable to speak to the Veteran, the staff person should advise the person calling on the Veteran's behalf to present to their nearest magistrate's office and request that an Emergency Custody Order (ECO) be issued. The staff person should also advise the person calling to contact 911 for emergency assistance if the Veteran poses an immediate danger to self or others.

m. SPC Reporting.

(1) The SPC is responsible for ensuring that data from all SBR and high-risk patient information is entered into the SPAN database in a timely manner and that appropriate medical center and VISN leadership is granted "read only" access to SPAN for their informational needs.

(2) The SPC will submit any requested additional reports and/or information to medical center leadership, VISN leadership, and the National Suicide Prevention Coordinator for the purposes of program monitoring, data collection, and performance improvement activities.

(3) The SPC, in collaboration with the Patient Safety Manager, is responsible for overseeing aggregate reviews involving all suicidal self-directed violence behaviors (suicide attempts and suicides).

n. SPC Coverage.

(1) When the SPC is on leave or otherwise unavailable, coverage for administrative functions (e.g., placement/removal of PRF for suicide risk, management of SPC reporting) will be provided by the SPC program support assistant. Coverage for clinical functions (e.g., Veterans Crisis Line coverage, responding to Suicide Risk Management consults, high-risk follow-up) will be provided by the Suicide Prevention Case Manager.

(2) In the event that both the SPC and Suicide Prevention Case Manager are on leave at the same time or are otherwise unavailable, the SPC is responsible for ensuring that coverage for clinical functions is provided by appropriate mental health staff. If the SPC is unable to ensure adequate coverage, the Chief, MHSL or his/her designee will assign appropriate mental health staff to provide coverage until the SPC or the Suicide Prevention Case Manager return.

ETHICAL DOMAIN:

a. Shared Decision Making with Patients

b. Professionalism in Patient Care

REFERENCES:

a. Medical Center Memorandum 658-116A-10, “Telephone Calls – Suicide or Homicide”, dated March 8, 2018.

b. Medical Center Memorandum 658-116A-09, “Detainment/Commitment Procedures”, dated September 23, 2015.

c. Suicide Risk Assessment Guide Reference Manual, http://vaww.mentalhealth.va.gov/files/suicideprevention/SuicideRiskGuide.doc NOTE: This is an internal VA Web site not available to the public.

d. VHA Directive 2008-036, “Use of Patient Record Flags to Identify Patients at High- Risk for Suicide”, dated July 18, 2008.

e. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, “Patients at High-Risk for Suicide”, dated April 24, 2008.

f. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, “Standardized Suicide Nomenclature (Self-Directed Violence) Classification System”, dated April 2010.

http://vaww.mentalhealth.va.gov/files/suicideprevention/SuicideRiskGuide.doc

g. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, "Suicide and Suicide Attempt Reporting Requirements", dated April 12, 2010.

h. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, “Behavioral Autopsy Program Implementation”, dated December 11, 2012.

i. Mental Health Service Line Policy/Procedure Memo 13-05, “Guidance on Patients’ Failure to Attend Appointments (No Shows)”, dated September 10, 2013.

j. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, “Guidance on Patients Failure to Attend Appointments (No Shows)”, dated August 6, 2013.

k. Deputy Under Secretary for Health for Operations and Management (10N) Memorandum, “Suicide Behavior Review and Reporting”, dated March 18, 2016.

FOLLOW-UP RESPONSIBILITY: The Chief, Mental Health Service Line.

RESCISSION: Medical Center Memorandum 658-116A-21, “Suicide Assessment, Intervention, and Documentation,” dated November 7, 2016.

EXPIRATION: June 6, 2021.

Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director