D.12 Attachment - Suicide Prevention VAPIHCS.pdf

DEPARTMENT OF VETERANS AFFAIRS

PACIFIC ISLANDS HEALTH CARE SYSTEM

HONOLULU, HAWAII 96819-1522

FACILTY POLICY MEMORANDUM

NO. 116-18-005

OCTOBER 5, 2018

PREVENTION AND MANAGEMENT OF SUICIDE

AND SUICIDE-RELATED BEHAVIOR

1. PURPOSE: To establish policy and procedures for the prevention and management of suicide and suicide related behavior among Veterans receiving services from VA Pacific Islands Health Care System (VA PIHCS).

2. POLICY: VA PIHCS will make every reasonable effort to prevent its Veterans from carrying out impulses or plans directed toward self-injury.

BACKGROUND: The rate of suicide in the Veteran population is higher than the general population because a large proportion of our Veterans have many of the risk factors that predispose them to suicide (post-traumatic stress disorder, substance abuse, mood and other mental disorders, life circumstance problems, and access to firearms). Clinicians need to be alert for: a history of suicidal behaviors or attempts, a sense of hopelessness, social isolation, recent losses, a sense of burdensomeness, and chronic medical illness associated with poorly controlled pain, terminal diagnosis, or loss of valued functions and self-esteem.

3. ORIGINAL EFFECTIVE DATE: November 23, 2010

4, DEFINITIONS:

a.Suicide and Suicide Attempt: Self-injurious acts (with or without serious injury) with the intent to die. Note that intent to die is judged by both subjective evidence (Veteran-reported) and objective evidence (behavior that suggests intent to die, such as: preparing a will, putting affairs in order, giving away prized possessions, inappropriate thanks/good-byes, and selection of highly lethal method of self-injury accompanied by efforts to prevent rescue). The concept of suicide requires that the action was self-inflicted and the person had the intent, purpose, aim or goal of death.

b.Self-harm behavior: Self-injurious act with a goal other than death, such as:

seeking help, punishing others and gaining attention (also known as "Instrumental Suicide-Related Behavior.") Such acts can lead to death (accidentally) and carry a high risk of repetition. Such behavior is often also referred to as "para-suicidal behavior".

c. Undetermined Suicide-Related Behavior: a self-inflicted potentially injurious behavior for which the intent is unknown. This would include Veterans who are unconscious, psychotic, delusional, demented, or for some reason unable to convey their intent.

d.Suicide Threat: Communication that suicidal behavior might occur.

DEPARTMENT OF VETERANS AFFAIRS FACILTY POLICY MEMORANDUM

PACIFIC ISLANDS HEALTH CARE SYSTEM NO. 116-18-005

HONOLULU, HAWAII 96819-1522 OCTOBER 5, 2018

e.Suicidal Ideation: Self-reported thoughts of engaging in suicidal behavior.

f. Lethality; Extent to which the method of self-harm is a medical dancer to life.

g. Suicide Risk Assessment: A clinical evaluation to determine the nature and degree of suicide risk/probability.

h. Imminent Risk: Level of risk at which suicidal behavior is thought likely within the next 72 hours unless interventions or safety precautions are taken.

i. Patient Record Flag — High Risk for Suicide: A category I flag placed on the Veteran's medical record that indicates the Veteran is at high risk for suicide.

5. PROCEDURE:

a. Veterans that present to VA PIHCS who are positive for depression (on the depression screen clinical reminder, or as clinically indicated) are screened for suicidal and homicidal ideation.

1) If Veteran is identified to be positive for depression via the depression screen clinical reminder, the Suicide Risk Identification Strategy, a three step screening process, is initiated. First level screen includes completion of the depression clinical reminder; second level screen includes completion of the Columbia-Suicide Severity Rating Scale, and third level screen includes completion of the Comprehensive Suicide Risk Evaluation. All three levels must be completed the same calendar day. Staff specific guidance on who can complete each level can be found in Attachment D.

2) If Veteran is identified to be positive for depression through any other means, VA clinical staff may use the MH Suicide Risk Assessment note template to screen for suicide or complete a direct provider to provider hand-off ("warm hand-off") to mental health.

a) In primary care settings, this may include referral to the Primary Care Mental Health integration team.

b) In CBOC settings, this may include referral the Mental Health Officer of the Day,

c) At the VA Ambulatory Care Clinic, this may include referral to the mental health triage team.

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FACILTY POLICY MEMORANDUM

NO. 116-18-005

OCTOBER 5, 2018

b. Veterans demonstrating suicidal behavior (serious threats or actual physical self-harm) on VA premises will not be left unattended during any aspect of the evaluation process. A direct provider to provider hand-off ("warm hand-off") is required. When a professional concludes that a Veteran is at imminent risk of suicide, he/she must take immediate and appropriate action to assure life safety, If the Veteran leaves the area,' efforts to locate the Veteran must be initiated immediately. If the Veteran cannot be located VA security, the local police department, Suicide Prevention Program, ACOS for Mental Health, and Patient Safety Manager should be notified. All staff are to follow protocol for missing patients as document in Management of Wandering & Missing Veteran/Resident Events (VA Policy No.00-11-023) c, When a Veteran reports or otherwise demonstrates suicidal ideation, urges, or intent, this information must be recorded in the medical record and suicide risk assessment should be performed within 24 hours. The professional receiving this information must complete all of this process up to the limits of their scope of practice. If the professional cannot fully complete both steps (documentation in CPRS and completion of MH Suicide Risk Assessment note), then a warm-hand off to mental health triage is required. If the Veteran is found to be at moderate or high risk then "Danger of Harm to Self' must be added to the Problem List.

Resulting decisions, interventions, or treatment plans will be documented in the Veteran's clinical record. Completion of the MH Suicide Risk Assessment note triggers an automatic CPRS alert to the suicide program.

d. VA health care providers who become aware of suicidal threats/behavior of a Veteran who is not on the premises are responsible for making every reasonable effort to protect the Veterans' welfare, This may include initiation of an Oral Ex Parte, notifying local police as described in the addendum on managing the suicidal caller, or contacting the Veterans Crisis Line for assistance

e. Utilization Review staff will add the Suicide Prevention Coordinator (SPC) and Suicide Prevention Case Mana9ers (SPCM) as additional signers to all admission notes related to inpatient psychiatric care,

f. Care in the Community Staff will add suicide prevention clinical staff to all community hospital notification notes when the admission diagnosis is related to suicide attempts, ideation, or self-injurious behaviors.

g, All VA PIHCS clinical staff is advised that the first person to become aware of suicidal behaviors or a suicide death is to complete the Suicide Behavior Report, a CPRS note located under the same note title. The Suicide Prevention team will receive notification of a completed suicide behavior report via automatic alert in

CPRS.

HONOLULU, HAWAII 96819-1522 OCTOBER 5, 2018

h. The Suicide Prevention Coordinator will immediately alert the ACOS, Mental Health Service and the Risk Manager of any suicide deaths when this information is received during regular business hours, If suicide death occurs during non-business hours the ACOS, Mental Health Services and Risk Manager will be advised on the next business day.

i. High Risk Determination: All Veterans who have been determined to be at High Risk for Suicide will be placed on the High Risk for Suicide List and receive a National Category I High Risk for Suicide Flag. The determination of high risk for suicide may occur through two means:

1) A full risk assessment has been completed by a Mental Health clinician and the Veteran's risk factors, protective factors, and warning signs indicate that the Veteran is currently at high risk for suicidal behaviors,

2) The Veteran has been admitted to an inpatient psychiatric facility for serious suicidal ideation or has exhibited suicidal behaviors which were motivated by the individual's intent to die.

j. Reporting Suicidal Behavior: If a Veteran makes a suicide attempt or discloses suicide intent while on the grounds of the VA PIHCS during normal business hours, the staff should notify the first available provider, Mental Health Triage, or VA's PSOD (MH Triage Pager: 299-2622; PSOD's pager: 299-2625). If the event occurs during non-business hours, staff should dial 911 immediately. The Suicide Behavior Report is completed when suicidal ideation turns into behavior such as making preparations to commit suicide, e.g.: buying a rope to hang oneself; buying a gun and/or ammunition in preparation to harm self; practicing holding gun to one's head to build courage and desensitization to carry out the act; stockpiling medications in preparation to overdose; searching Internet for a specific way to commit suicide; giving away belongs and/or finalize arrangements with plan of suicide; writing goodbye letters and/or a suicide note; behavior that is thwarted.

The individual who first becomes aware of the event will complete a Suicide Behavior Report in CPRS within 24 hours after the event. When the Veteran is on the grounds, the attending or staff physician and/or the primary therapist should be summoned to the scene when at all possible. The Veteran must never in these circumstances be left unattended. If appropriate (e.g., weapon involved) VA Security should be notified. A Heads Up and Issue Brief notifying the PENTAD should be completed when the suicidal behavior results in death or may generate media interest.

k. The Suicide Behavior Report should not be used for suicide ideations that are without plan formulation and do not require admission to a more secure facility, but

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FACILTY POLICY MEMORANDUM

NO. 116-18-005

OCTOBER 5, 2018

such suicide ideations should be monitored and documented with treatment as indicated, such as the development/modification of a Suicide Prevention Safety Plan and treatment plan.

I, High Risk For Suicide Veteran Record Flags And Safety Planning:

1) The primary purpose of the patient record flag "High Risk for Suicide" is to communicate to VA staff that a Veteran is at high risk for suicide, The presence of a flag should be considered when making treatment decisions. The Suicide Prevention Team and the Veteran's mental health providers (when possible) will determine if a High Risk for Suicide flag will be placed on the Veteran's medical record and also when it is to be removed, according to protocol.

2) The clinician needs to consider frequent follow-up appointments, involving significant others in care planning, and limiting access to means of harmiog oneself for flagged patients when possible. During the first 30 days after patient record flag "High Risk for Suicide" assignment the Veteran must be seen' four times and a suicide risk assessment and Suicide Prevention Safety Plan will be reviewed/updated at each appointment. Two of these visits must occur between days 0-14 and two visits must occur between days 15-31. The treatment plan should be updated when clinically appropriate to include interventions to reduce suicide risk, After the initial 30-day period, the Veteran must be seen at least monthly with suicide risk assessment and Suicide Prevention Safety Plan review/update at each appointment.

3) Front line staff needs to be aware that if they are concerned about a Veteran's safety they are to contact the first available provider, MH Triage, or PSOD during busin6ss hours. The absence of a High Risk for Suicide PRF on a Veteran's record does not indicate that the Veteran is not at risk for suicide.

Risk factors and warning signs for suicide that were not previously exhibited by the Veteran can occur at any time. In the event of concerns for increased suicide risk, suicide prevention program staff should be added as additional signers to the CPRS note containing the relevant information.

4) The use of the Patient Record Flag "High Risk for Suicide" is restricted to addressing immediate clinical safety issues, It is important to ensure that usage of a Patient Record Flag is limited to only those Veterans at high risk for suicide, and only for the duration of the increased risk for suicide, The Patient Record Flag is removed as soon as it is clinically indicated to do so after being on the medical record for30 days. This is especially important to minimize the risk of undue stigmatization for the Veteran, and to maintain the value of the Patient Record Flag system as an alert to an immediate clinical safety concern, All High risk for Suicide PRFs must be reviewed at least 90 days to determine if flag

HONOLULU, HAWAII 96819-1522

FACILTY POLICY MEMORANDUM

NO. 116-18-005

OCTOBER 5,2018

should be continued, inactivated, or transferred to other VA facility. This review must be document in the Veteran's medical record.

5) All Veterans who are flagged for High Risk MUST have a completed Suicide Prevention Safety Plan within the first 72 hours of flag placement when outpatient and before discharge when on the inpatient psychiatric unit. If the outpatient cannot keep an appointment within 72 hours the reason must be documented in CPRS and the Suicide Prevention Safety Plan must be developed at the Veterans' next visit. If there is no safety plan completed, a documented reason must be placed into CPRS with rationale, i.e., Veteran refused, unable to contact Veteran etc.

6. RESPONSIBILIITES:

a. When a Veteran has been determined to be at High Risk for Suicide, the Suicide Prevention Team will:

1) Assure that the Veteran is placed on the High-Risk List and receives a National Category I High Risk Flag in CPRS.

2) Assist with expediting Veteran into mental health care and provide mental health coordination/case management assistance until Veteran is fully assigned to a mental health care team.

3) Monitor the Veteran's CPRS chart for missed mental health appointments and ensure suicide prevention documentation protocol is completed appropriately by Veteran's primary mental health provider.

4) Contact Veteran to inform him/her of high risk flag placement and provider education on availability of crisis resources as well as available supportive services from suicide prevention program.

5) Assist the Mental Health and Primary Care providers in assuring that the Veteran receives appropriate care by providing consultative services.

6) Place Veteran on the Suicide Prevention's Mail Program (regular personal notes to maintain communication and remind high risk Veterans of available crisis resources).

b. Mental Health Staff will:

1) Assure that the Veteran is scheduled for a minimum of 4 visits within 30 days of flagging or a flagged patient being discharged from inpatient psychiatry for

HONOLULU, HAWAII 96819-1522 OCTOBER 5, 2018

suicidal ideation or attempt, During this initial 30 day follow-up period, two visits must occur between days 0-14 and two visits must occur between days 15-31.

2) Contact the Veteran if there is a no-show (see MH Revised No-Show Appointment SOP).

3) Assure that the Veteran participates in development of the Suicide Prevention Safety Plan and receives a copy of it for future reference and implementation. The Suicide Prevention Safety Plan must be reviewed and updated at each of the 4 visits during the initial 30 day period and 1 time monthly thereafter.

c. The Medical Center Director has overall responsibility for implementing this policy.

d. Managers of inpatient units will assure a safe environment for any Veterans thought to be at risk for suicide. All VA staff who may come in contact with suicidal Veterans will receive adequate training in the recognition and management of such Veterans; this training is completed during New Employee Orientation

e. All VA personnel are responsible for reporting any person in the medical center who demonstrates suicidal behavior. When any person expresses suicidal behavior or threats, it will be reported to the charge nurse, physician, primary provider, other clinician in the area, the VA Police, and complete a Suicidal Behavioral Report. If the behavior appears to pose immediate danger, a Behavior Code (code grey) should be called if necessary to assure Veteran/staff safety.

7. REFERENCES:

a. VHA Directive 2008-036, Use of Veteran Record Flags to Identify Veterans at High Risk for Suicide dated July, 2008 — or most current version.

b. VHA Directive 1071, Mandatory Suicide Risk and Intervention Training for VHA Health Care Providers, dated December 2017

c. VHA Directive 2010-053, Patient Record Flags, corrected copy dated February 3, 2011 — or most current version.

d. VHA Handbook 1160,01, Uniform Mental Health Services in VA Medical Centers and Clinics, dated September, 2008 — or most current version.

e. Management of Wandering & Missing Veteran/Resident Events (VA Policy No.00-11-023), dated January 5, 2011 — or most current version,

f. Managing Disturbed Behavior; Violent, Aggressive, or Suicidal Persons; "Code Grey Policy" (Policy No. 00-13-019), dated March 2013.

hit Gufôwski, MHA, FACHE Director, VA Pacific Islands HCS

DISTRIBUTION: A/Electronic

DEPARTMENT OF VETERANS AFFAIRS

PACIFIC ISLANDS HEALTH CARE SYSTEM

HONOLULU, HAWAII 96819-1522

FACILTY POLICY MEMORANDUM

NO. 116-18-005

OCTOBER 5,2018

8. RESCISSION:

a. Facility Policy Memorandum 116-10-005: Prevention And Management of Suicide And Suicide-Related Behavior, dated July 2, 2013,

9. ATTACHMENTS:

a. MHS SOP 024 Appointment No-Shows

b. MHS SOP 049 Managing the Potential Suicidal Caller

c. Safe Response to the Suicidal Caller

d. Suicide Risk Identification Strategy Staff Specific Guidance

10.REVIEW DATES:

October 2019, 2020, 2021 and 2022

11.REISSUE DATE:

October 2023

12. FOLLOW-UP RESPONBILITY: Suicide Prevention Coordinator

Tiara R.

Peterkin 466154

Digitally signed by Tiara R. Peterkin 466154 Date: 2019.01.14 13:03:59 -1000

Tiara Peterkin, LCSW Suicide Prevention Coordinator

ATTACHMENT A

Department of Veterans Affairs Mental Health Service Pacific Islands Health Care System SOP 024 Honolulu, HI 96819-1522 7 January 2019

MHS SOP 024: MENTAL HEALTH APPOINTMENT "NO-SHOWS"

PURPOSE:

To provide guidance to mental health treatment programs regarding the appropriate action to talce when a patient fails to keep a scheduled appointment. It is the responsibility of each clinician to review daily "No-Shows" for his/her clinic and to make clinical decisions regarding potential risk of missed appointment, The procedures outlined are designed to enhance patient safety.

2. PROCEDURES:

a. Patients who miss scheduled mental health or substance abuse appointments will be contacted in most cases by any staff member.

b. Follow-up is not necessary when veterans cancel appointments and reschedule.

c. Follow-up will be by telephone in most cases. At least three attempts should be made to reach the patient and documented in the patient's medical record. This is to be done within one week. When the third attempt fails, program clerks will send a computer generated letter on a missed appointment by the eighth day following the missed appointment.

d. However, patients who report having suicidal thoughts or who have made a suicide attempt require special consideration which is outlined in Part d (2) below.

(1) No-show patients who are not flagged as High Risk: The clinician will document the missed appointment in CPRS. The clinician attempts to contact the patient by phone. If the first contact attempt fails, the administrative staff will attempt contact two more times. These attempts are documented in

CPRS,

(2) No-show patients who are flagged as High Risk: The clinician must promptly telephone any high risk patient who fails to appear for his/her scheduled appointment. This attempt is documented in CPRS. The clinician will write a progress note documenting that the high risk patient did not keep the scheduled appointment and documenting his/her attempts to reach the patient. The provider must note date and time of personal contact with patient and document the patient's stated reason for not keeping the appointment, provider's assessment of the patient's level of acuity, and the date/time of the rescheduled appointment. If the clinician is unable to reach the patient by phone on the first attempt, and the patient is not felt to be imminently dangerous, the provider will to attempt contact the patient two more times by phone. The clinician may also request a letter be sent, asking the patient to immediately contact the provider/clinic to reschedule the appointment. If contact is unsuccessful for high risk patients after three attempts, a letter inviting the patient back to treatment will be sent by the clinician. The suicide prevention coordinator and/or suicide prevention case manager will collaborate with the treatment provider(s) to determine the next appropriate step utilizing clinical judgment and the pre-developed Safety Plan, if possible. Contacting local law enforcement for assistance is recommended when risk of harm is deemed to be imminent.

(3) If at any time during this process, a clinician becomes concerned when risk of harm is deemed to be imminent the clinician may proceed with an Oral Ex Parte

(MH-2), contact police (MH-1) or community Crisis Mobile Outreach team, who can be reached at 808-832-3100. Computerized Patient Record System

(CPRS) documentation of this action and the outcome will be entered. The

Suicide Prevention Coordinator is added as cosigner on the progress note.

e. Supervisors will audit compliance with the SOP by performing periodic chart reviews.

3. RESCISSION:

SOP 024 Mental Health Appointment No-Shows, dated August 04, 2014.

4. ATTACHMENTS:

A. None

5. REISSUE DATE: August 2019

6. FOLLOW-UP RESPONSIBILITY: Program Manager, Ambulatory Mental Health

David M Bernstein

X 232794

Digitally signed by David M Bernstein 232794 Date: 2019.01.1414:11:49 -10'00'

DAVID M. BERNSTEIN, M.D.

ACOS, Mental Health Service

ATTACHMENT B

Department of Veterans Affairs Pacific Islands Health Care System Honolulu, HI 96819-1522

Mental Health Service

SOP 049

7 January 2019

PROTOCOL FOR MANAGING TELEPHONE CALLS INVOLVING

POTENTIALLY SUICIDAL VETERANS

1, PURPOSE: The purpose of this policy is to outline procedures for handling and reporting telephone calls involving potentially suicidal veterans, 2, POLICY: To provide guidelines for all VA Pacific Islands Health Care System (VAHHCS) personnel when confronted with telephone calls involving potentially suicidal veterans,

3. DEFINITIONS: Potentially suicidal veterans: veterans with suicidal ideation, Suicidal ideation: any thought of engaging in suicide-related behavior, Ex Parte Order: An order from a Family Court judge directing the local police to transport a person to a designated hospital emergency room for an involuntary psychiatric evaluation, This may result in an involuntary psychiatric hospitalization.

4, RESPONSIBILITIES: Applicable to all staff at VAPIHCS.

5. PROCEDURES:

A. If an employee receives a call from an individual with suicidal ideation, the following actions shall be taken:

(1) Attempt to get the caller's name, phone number and present location from where he/she is calling. Use the SAFE script (Attachment A), If the caller refuses to give this information, do not persist in asking.

(2) The staff member answering the phone should reassure the caller that he/she will get appropriate help and will transfer the caller to a provider.

(3) Transfer the call to a trained mental health professional. Stay on the line until you are sure that the MH provider has answered.

(4) If you are unable to transfer the call to an identified MH provider due to the fact that the line is busy or there is no answer, return to the caller and assure them that you are locating a MH provider, Call the MH Triage pager (808) 299-2622 (in the CBOC, knock on the door of the MH Provider to alert him/her of an emergent call, If MH staff is not immediately available, contact the lead RN at CBOC). If there is still no response, call the PSOD at (808) 299-2625. CBOC: contact the Nurse Manager, If you are unable to transfer,the call to an identified MH provider due to the fact that the line is busy or there is no answer, return to the caller and assure them that you are locating a MH provider. Immediately inform the individual to whom the call is transferred that this is an emergency. Briefly explain the situation, and provide the caller's telephone number and address unless he/she has refused to provide it, B. Mental Health Professional: The appropriate procedure to be taken for callers threatening suicide is as follows:

(1) Determine the caller's identity, location and telephone number from which he/she is calling,

(2) Listen to the caller's statement of the problem in an understanding and empathetic manner,

(3) When the caller reaches a hesitant point, try to cairn the caller down (i.e. let him/her know that professional help is available and the VATIFICS is interested in helping him/her work the problem out,

(4) Make a clinical assessment of the risk for suicide using the risk and protective factors outline in the Suicide Risk Assessment Guide. Another tool is the Suicide Risk Assessment template in CPRS,

(5) In the case of high risk callers where immediate hospitalization appears necessary to prevent injury or death:

(a) Suggest that he/she come to or preferably have someone bring him to the MH Triage in Honolulu (or CBOC on neighbor islands). If it is after clinic hours, suggest that he go to the nearest emergency department for help.

(b) For service connected veterans, ambulance transportation to the hospital can sometimes be arranged,

(c) If the location is known, and the caller refuses to voluntarily come to the emergency department, the MH provider should initiate a request for an Oral Ex Parte Order,

(d) Provide the caller with the phone number for the National Suicide Prevention Hotline for additional support (800) 273-8255.

(e) The call should be documented in CPRS.

(6) The Suicide Prevention Team [(808) 433-1695] should be notified of the case.

(7) Moderate/low risk:

(a) The MH provider will provide crisis intervention counseling on the phone.

(b) The MH provider will encourage the veteran to come to MH Triage or to CBOC within one working day.

(8) After hours call: Due to the "Alternative Work Schedule" at the Acute Care Clinic in Honolulu there may be times when certain staff members may receive a telephone call from a suicidal caller after MH Triage is no longer available. At that time the staff member should execute the following actions:

(a) Administrative staff should obtain veteran's contact phone number and location, if possible (use SAFE script, see attachment A). If the veteran is unwilling to provide the information, do not push him/her, Let the veteran know that you will stay on the line with him until you locate help.

(b) Transfer the call to a MR provider. If the MR provider number is busy or does not answer, personally notify someone in the area to contact a MH provider. If the administrative person is alone, keep the caller engaged on the line and reassure them that you are going to connect

David M Bernstein

X 232794

Digitally signed by David M Bernstein 232794 Date: 2019.01,14 10:50:28 -1000' them with a MH provider, If you are unable to contact a MH provider, transfer the call to VA inpatient psychiatry (3B-2) at (808) 433-0318, then when MH provider is contacted, give the veteran's name, location, and phone number so that the MH provider can call the veteran as well.

(c) The MH provider who receives a call from a suicidal veteran after hours must determine the level of suicide threat, Use the Suicide Risk Screen in CPRS templates. Type in the word "suicide" under "Progress Note Title" in CPRS and the MH Suicide Risk Assessment will pop up. If the threat is High, instruct the veteran to go to the nearest emergency department. If the veteran does not agree to go the emergency department, execute an Ex Parte Order. If the threat is moderate or low, instruct the veteran to come to MHTriage on the next working day.

6, REFERENCES: None

7, RECISSIONS: Protocol For Managing Telephone Calls Involving Potentially Suicidal Veterans, dated May 2015.

8, ATTACHMENTS: Safe Response to the Suicidal Caller

9. REISSUE DATE: May 2024

10, FOLLOW-UP RESPONSIBILITY: Suicide Prevention Program, MT-IS

DAVID M. BERNSTEIN, M.D.

ACOS, Mental Health Service

ATTACHMENT C

Attachment A to MHS SOP 049 SAFE Response to the Suicidal Caller

S Stay calm on the phone with the caller. Notify another employee in the immediate area that you have a suicidal caller on the line. That person should contact a mental health provider that you can transfer the call to, Ask the person for their name, address, and phone number just in case you lose the call or the veteran hangs up.

A Assure the caller that you're there to help them. (Examples — "You must be feeling very bad. I'm glad you called. We want to help you, and we don't want you to harm yourself" and "Please stay with me on the line while I get you the help that you need.") Avoid making critical, judgmental, or minimizing comments to the caller. (Examples — "Oh, you're not really suicidal; you just want to be admitted to the hospital" or "People who kill themselves are cowards.")

F Forward the call to a mental health professional who can help. Make sure the provider knows the call is being transferred and they are there to take the call.

E Encourage the caller to tell you as much about them as they will allow (name, address, phone number, social security number), but try not to push too hard if the caller isn't willing to provide the information. Do not be concerned about the caller's veteran status or eligibility at this point. Focus on getting the caller to a mental health provider.

SAFE Script for a Suicidal Caller

Caller: "Hello. . I'm feeling depressed, and I've been thinking of killing myself."

VA Staff: "You must be feeling very bad. I'm really glad that you called us for help. May I transfer you to someone that can help?"

If Caller says: YES VA Staff, "I'll stay on the line with you, while we get you the help that you need.

If Caller says: NO ---VA Staff, "I understand that it may be hard for you to talk about what's going on, but you deserve to get the best professional help we have here. I'm really glad you called us. "By the way, my name is . What's your name? Are you by yourself? If the doctor wants you to come to the hospital, would you have a way of safely making it here? Would you need help with transportation? Would you be willing to give me your address and phone number?"

Points to keep in mind:

• Caller is seeing suicide as the only solution to his/her problem. (Thinking becomes muddled and focused, so unable to see any other options.)

• Caller wants help or he/she would not be calling.

• Keeping these two points in mind might help you to remain CALM so that you can

LISTEN and provide some EMPATHETIC SUPPORT while waiting for mental health professional to take over the call. Try to get as much information about the caller as you can: name, address, phone number, social security number, where is he/she at this time, BUT not at the expense of losing the call. If person is not forthcoming with that information just keep him/her talking about whatever person wishes to talk about.

Order to follow when looking for Professional Assistance: If there are no mental

• health providers available then call in the following order:

1) Triage Pager: (808) 299-2622

2) PSOD Pager: (808) 299-2625

REMEMBER DON'T LET GO OF THE CALLER UNTIL YOU KNOW

THAT HE OR SHE IS CONNECTED WITH SOMEONE ELSE.

SAFE:

Specific Telephone Situations and How to Manage the Call

Situation: Response:

Veteran calls and 1) Ask a colleague to locate a mental health professional and let expresses them know you will be transferring the call to his or her suicidal feelings. extension.

You have a 2) Keep the caller engaged on the line. Use SAFE script if colleague necessary. Try to get as much identifying information as nearby. possible (name, address, phone number, social security number) so if you get disconnected as you transfer the call to the mental health provider or the caller hangs up you will have the information necessary for the mental health provider to get EMS services to the patient.

3) Transfer call to mental health provider.

Situation: Response:

Veteran calls and 1) Assure caller that you want to help and are going to do expresses everything you can to get them connected with a mental health suicidal feelings. professional.

You are all alone 2) Keep the caller engaged on the line. Use SAFE script if in the reception necessary. Try to get as much identifying information as area with no possible (name, address, phone number, social security other staff number) so if you get disconnected as you transfer the call to member the mental health provider or the caller hangs up you will have available to help the information necessary for the mental health provider to get you. EMS services to the patient.

3) Connect with a mental health professional, let them know that you have a suicidal caller on the line and give as much information as possible to the clinician before you transfer the call, Situation: Response:

Veteran calls and 1)Assure caller that you want to help and are going to do expresses everything you can to get them connected with a mental health suicidal feelings. professional.

There is no one 2) Keep the caller engaged on the line. Use SAFE script if available to necessary. Try to get as much identifying information as transfer the call possible (name, address, phone number, social security

to. number).

3) Call the Triage Pager or PSOD pager in the order listed above.

Connect with a mental health professional, let them know that you have a suicidal caller on the line and give as much information as possible to the clinician before you transfer the call.

Attachment D

Department of Veterans Affairs (VA) Suicide Risk Identification Strategy

Staff Specific Guidance

Primary*, secondary** screening and Comprehensive Suicide Risk Evaluation (CSRE), which contains a detailed assessment and disposition, should be completed according to staff scope of practice. The final disposition/level of care decision based upon screening and/or CRSE must be completed by a VHA Health Care Provider, which is defined as a licensed independent provider (LIP) or advanced practice provider. See below for further detail,

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Yes Yes No

Yes No No i 1;tii!, Yes Vest No ,.,,i;?:.iii[..ol:•'.,1;1,1,F•

;Pri.

*Primary Screen: The Patient Health Questionnaire-2 (PHQ-2) plus item #9 from the PHQ-9 and/or the Primary Care Posttraumatic Stress Disorder-DSM-5 version (PC-PTSD-5) plus item #9 from the PHQ-9, which will be accessed via the Clinical Reminder System or Mental Health Assistant

**Secondary Screen: The Columbia- Suicide Severity Rating Scale (C-SSRS) Screener

IRNis can administer the secondary screen via Mental Health Assistant but they cannot administer the secondary screen via the Clinical Reminder System becatise it contains disposition

'Medical Doctor/Doctor of Osteopathic Medicine; 2Doctor of Philosophy/Doctor of Psychology;

'Licensed Clinical Social Worker/Licensed Master of Social Work/Licensed Independent Social Worker;

4Licensed Marriage and

Family Therapist; 'Licensed Professional Mental Health Counselor; 'Licensed Practical Nurse;

7Registered Nurse; 'Advanced Practice Registered Nurse: Nurse Practitioner/Clinical Nurse Specialist;

9Physician's Assistant; 1°Unlicensed Assistive Personnel, including Health Tech, Medical Assistant, and Nursing Assistant.

Note: A trainee in ANY of these categories may complete each step marked with a "Yes" with an appropriate cosigner