D.15 36C26126R0014 SOP - Suicide Prevention.docx

SUICIDE RISK IDENTIFICATION AND PREVENTION STRATEGY

SOP MH-116-45

March 31, 2025 SOP MH-116-45

VA Northern California Healthcare System (VANCHCS) Mather, CA 95655

Signatory Authority:

Associate Chief of Staff, Mental Health Responsible Owner:

Suicide Prevention Program Manager Service Line(s):

Mental Health (116) Effective Date:

March 31, 2025 Recertification Date:

March 31, 2030

1. SUMMARY OF CHANGES

This SOP revision includes the process for risk screenings and evaluations for all services across the facility.

2. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures for risk screenings and evaluations for the entire Veteran community and enrolled Veterans served by the Department of Veterans Affairs Northern California Health Care System (VANCHCS). This facility-wide SOP must be followed by all VANCHCS staff during their routine daily operations in all settings.

b. This facility wide SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1160.07, Suicide Prevention Program, dated May 24, 2021; VHA Memorandum 2022-11-23, Suicide Prevention Coordinator Guide, updated December 2022; Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation Update, dated November 23, 2022; VHA Memorandum 2025-1-7, Suicide Risk Screening and Evaluation Requirements and Implementation Update; High Risk for Suicide Patient Record Flag Referral Process (HRS-PRF) and Updated Progress Notes, dated February 2, 2022,VHA Memorandum 2017-06-30, Eliminating Veteran Suicide: Enhancing Acute Inpatient Mental Health and Residential Rehabilitation Treatment Program (RRTP) Discharge Planning and Follow-up, dated June 12, 2017, and The Joint Commission, National Patient Safety Goal for Suicide Prevention, NPSG 15.01.01.

3. PROCEDURES

a. Suicide Prevention. All VANCHCS personnel are responsible for identification and reporting of potential suicide risks, including environmental conditions and Veteran behaviors. Staff will utilize evidenced based practices and nationally recommended clinical interventions specifically The Columbia-Suicide Severity Rating Scale (C-SSRS) and Comprehensive Suicide Risk Evaluation (CSRE) to identify Veterans who may be at risk for suicide.

b. Two Stage Process. VANCHCS utilizes a two stage, standardized, evidence-based suicide risk screening and assessment process. The first stage consists of a screen with six questions from the Columbia Suicide Severity Rating Scale screener (C-SSRS). The final stage, VA’s Comprehensive Suicide Risk Evaluation (CSRE), is a standardized template with more in-depth questions related to suicidal ideation, history of attempts, assessment for warning signs, risk factors, protective factors, and reasons for living.

c. Annual Screening.

(1) Annual Suicide Screening (C-SSRS). Annual Suicide Screening (C-SSRS) will be initiated via clinical reminders and a pop-up will be active in a Veterans Electronic Health Record (EHR) chart starting 30 days before their annual C-SSRS is due. Reminders will continue to appear anytime the Veterans chart is opened and is only deactivated once the C-SSRS is completed. Minimum screening requirements for various settings are outlined in Appendix B, Department of Veterans Affairs Suicide Risk Identification Strategy Minimum Requirements by Setting.

(1) Responsible Areas. All areas serving Veterans are responsible for completing the Annual Suicide Screening (C-SSRS) and coordinating the completion of the Comprehensive Suicide Risk Evaluation (CSRE) for a positive screen. Service areas that have an internal Licensed Independent Practitioner (LIP) within their program will have the respective LIP complete the Comprehensive Suicide Risk Evaluation (CSRE), while those that do not have an LIP will complete a warm hand-off for the positive screens to an LIP. Instructions for warm hand-offs are below in 3, d, (2) Positive Screen. Responsible areas include, but are not limited to the following: Audiology, Acute Inpatient Psychiatry, Chaplain Services, Community Living Centers/CREC, Complementary & Integrative Health/Move/Whole Health, Emergency Department, Home Based Primary Care, Homeless Program, Interfacility Partners (Environmental Registry, Clinical Resource Hub), Inpatient Medicine, Medicine Specialty Care, Mental Health, Ophthalmology/Optometry, Palliative & Hospice, Primary Care, Rehabilitation and Prosthetic Services, Social Work Service, Surgical Specialty Care, Telephone Ancillary Care Case Management, Urgent Care Clinic, and Women’s Health Services.

d. Risk Evaluation.

(1) When a Comprehensive Suicide Risk Evaluation (CSRE) is required, a pop-up window will be active in a Veteran’s CPRS chart notifying all staff that the CSRE must be completed as applicable. Pop-up reminders will continue to appear anytime the Veteran’s chart is opened and is only deactivated once the CSRE is completed or after 24 hours from the initial positive C-SSRS. The CSRE must be completed by an LIP. See Appendix C (Risk ID C-SSRS and CSRE Templates) for printable examples of the screening tools. The CSRE must be completed by a Licensed Independent Provider (LIP) as defined in Appendix A, Department of Veterans Affairs Suicide Risk Identification Strategy Staff-Specific Guidance.

(2) Positive Screen. A positive C-SSRS for suicide risk (Yes answer to question # 3,4,5,6, and/or 8) requires the Comprehensive Suicide Risk Evaluation via the CSRE note to be completed same day (or within 24 hours if hospitalized).

(3) Response Time. Service areas that do not have an LIP to complete the CSRE will coordinate the completion of the CSRE via the use of Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink. Subsequently, an LIP from the MH service will respond via chat within 5 minutes from the time the form is submitted. Coordination efforts will then continue via chat on how best to meet with the Veteran. Should the provider not receive a chat response within 5 minutes, the provider can contact a Suicide Prevention Team member as outlined in Appendix E.

(a) Veteran Decline Warm Hand-off. Should the Veteran refuse the warm hand-off, the provider can ask the Veteran for the best time and contact method for the LIP to reach the Veteran the same day. This additional information can be included in the form or in subsequent chat messages. Please note that for any veteran reporting imminent danger to self or others (current suicide ideation and/or homicide ideation with intent to act, plan to act, and means to carry out the plan), the provider will contact VA police or dial 911.

(4) End of Day. Should the notification for a positive screen be submitted after 4 pm, an LIP will respond the next day to coordinate the completion of the CSRE. If there is a concern to have the Veteran speak with someone the same day, and it is after 4 pm, the provider can contact the Veterans Crisis Line (988 select 1) as a professional third party. Please note that for any veteran reporting imminent danger to self or others (current suicide ideation and/or homicide ideation with intent to act, plan to act, and means to carry out the plan), the provider will contact VA police or dial 911.

(a) Audiology. When a CSRE is needed, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(b) Acute Inpatient Psychiatry.When a CSRE is needed, the service will utilize a LIP internal to their program to complete the CSRE. If needing additional consultation/questions answered, the service may contact the Suicide Prevention Team members (see Appendix E).

(c) Chaplain Service. Staff will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink. The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(d) Clinical Resource Hub. Clinical Resource Hub will continue to use existing channel with MH Access, https://teams.microsoft.com/l/channel/19%3AlZ3xlslgB2E4agRrOIKZOX_9cSCdRKJ-dT0XhOCco401%40thread.tacv2/General?groupId=96ccd66f-b402-4ac2-9493-8ad87092f55b&tenantId=e95f1b23-abaf-45ee-821d-b7ab251ab3bf

(e) Community Living Centers/CREC. Staff will continue to coordinate with their internal LIP to complete the CSRE. If needing additional consultation/questions answered, the service may contact the Suicide Prevention Team members (see Appendix E).

(f) Complementary & Integrative Health/Move/Whole Health. When a CSRE is needed, the service will utilize an established Teams chat with Primary Care Mental Health Integration (PCMHI) to coordinate with an LIP from PCMHI to complete the CSRE. Please see Appendix G, for additional instructions.

(g) Emergency Department (ED). Triage nurses complete C-SSRS with every patient who comes to the ER (embedded in triage note). With a positive C-SSRS, a MH Inpatient Consult pops up, pre-filled, that the nurse then signs to request Behavioral Health Inpatient Care Unit (BHICU) to complete a CSRE prior to the Veteran’s discharge from ER. The nurse offers Suicide Prevention Safety Planning to the Veteran and completes it with Veteran before discharge if Veteran is willing.

(h) Environmental Registry. When a CSRE is needed from a interfacility partners, such as Environmental Registry, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(i) Home Based Primary Care. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If needing additional consultation/questions answered, the service will contact the Suicide Prevention Team members (see Appendix E).

(j) Homeless Program/HUD-VASH. When a CSRE is needed, the service will use an LIP internal to their program to complete the CSRE. If needing additional consultation/questions answered, the service will contact the Suicide Prevention Team members (see Appendix E).

(k) Interfacility Partners. When a CSRE is needed from interfacility partners, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(l) Inpatient Medicine. If the positive C-SSRS is screened during an inpatient stay, the service will continue to notify the BHICU unit for completion of the CSRE within 24 hours of the screen or before the Veteran discharges from the inpatient unit.

(m) Medicine Specialty Care: When a CSRE is needed, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink. The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(n) Mental Health. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If needing additional consultation/questions answered, the service will contact the Suicide Prevention Team members (see Appendix E).

(o) Ophthalmology/Optometry. When a CSRE is needed, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink. The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(p) Palliative & Hospice. When a CSRE is needed, the service will use an LIP internal to their program to complete the CSRE. If an LIP is not available, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink. The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(q) Primary Care. If the positive C-SSRS is completed by Patient Aligned Care Team (PACT), staff will alert the PCMHI team at that site for follow-up with the Veteran after their PACT appointment the same day, via the established Teams chat or channel. Please see Appendix G for additional instructions.

(r) Primary Care Mental Health Integration. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If needing additional consultation/questions answered, the service will contact the Suicide Prevention Team members (see Appendix E).

(s) Rehabilitation Prosthetic Services. When a CSRE is needed, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(t) Social Work Services. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If needing additional consultation, the service will contact the Suicide Prevention Team members (see Appendix E).

(u) Surgical Specialty Care. If a CSRE is needed, the service will complete, complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(v) Telephone Ancillary Care Case Management. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If one is not available, the service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(w) Urgent Care Clinic (UCC). The triage nurse completes the C-SSRS with every patient who comes to the UCC (embedded in triage note). When a positive C-SSRS is encountered, the nurse or service will complete Microsoft Form, Positive-Suicide Screen Notification and Warm Hand-off, via https://forms.office.com/g/CBdB4CvpAq?origin=lprLink.

The form will be immediately received by a MH provider who will then reach out to the provider via Teams to coordinate the completion of the CSRE.

(x) Women’s Health Services. When a CSRE is needed, the service will utilize an LIP internal to their program to complete the CSRE. If needing additional consultation, the service will contact the Suicide Prevention Team members (see Appendix E).

e. Imminent Danger. For any Veteran reporting imminent danger to self or others (current suicide ideation and/or homicide ideation with intent to act, plan to act, and means to carry out the plan), staff will contact VA police or dial 911.

f. Suicide Behavior and Overdose Report. Licensed clinical providers (medical and mental health) are required to complete the Suicide Behavior and Overdose Report (SBOR) note template in CPRS for Veterans who have overdosed, attempted suicide, engaged in suicide preparatory behavior, or died by suicide occurring in the last 12 months. See Appendix H for a printable example of the SBOR.

g. Suicide Prevention Safety Plan. Completion of the Suicide Prevention Safety Plan (SPSP) note template in CPRS should be strongly considered for a Veteran with any identified suicide risk. An SPSP is required whenever a Veteran is assessed as intermediate or high risk for suicide and whenever a Suicide Behavior and Overdose Report is completed.

(1) If a SPSP already exists and does not need any changes per the Veteran, the provider can complete a Suicide Prevention Safety Plan Review/Decline note and select the option that states “Veteran and clinician reviewed prior safety plan together; no changes indicated at this time.”

(2) If a prior SPSP needs to be revised, or if there is no prior plan, the provider will complete a full SPSP note with the Veteran. If a Veteran declines to do a SPSP, the provider will complete a Suicide Prevention Safety Plan Review/Decline note and choose the option that states, “Veteran refused offer to complete a suicide prevention safety plan.”

(3) A copy of any completed SPSP developed with a Veteran will be provided to the Veteran upon completion. If completed over the phone, a copy of the plan will be provided via mail or at the next face-to-face appointment, whichever will happen sooner. See Appendix I for a printable example of the SPSP.

h. Documentation. Following identification of any level of suicide risk, documentation in CPRS should clearly indicate a plan to mitigate the risk, such as hospitalization, safety planning, scheduling of outpatient mental health appointment, etc. This level of documentation will be completed by the LIP or treating MH team member completing the CSRE. To assist providers in determining level of risk and recommended interventions, please see Appendix J, for the Therapeutic Risk Management – Risk Stratification Tool provided by the VA Rocky Mountain Mental Illness Research Education Clinical, Centers of Excellence (MIRECC).

i. Emergency Department. Any Veteran that has been assessed in the Emergency Department (ED) using the SRE-C and determined to be at intermediate or high acute or chronic risk for suicide and then planned for discharge from ED without inpatient hospitalization meets the requirements for additional follow-up as laid out in the Suicide Prevention in the Emergency Department (SPED) flow diagram in Appendix K.

j. Training Requirements.

(1) For Clinicians. On an annual basis, all health care providers will complete “Suicide Risk Management Training for Clinicians Refresher,” via the VA Talent Management System (TMS) Course #43820, https://va-hcm03.ns2cloud.com/learning/user/catalogsearch/catalogSearchDispatchAction.do?searchType=filteredSearch&keywords=43820#. Compliance will be monitored by the Education Department and Suicide Prevention staff.

(2) Non-clinical staff. On an annual basis, all non-clinical staff will complete “Operation S.A.V.E. Refresher,” VA TMS Course #30535, https://va-hcm03.ns2cloud.com/learning/user/catalogsearch/catalogSearchDispatchAction.do?searchType=filteredSearch&keywords=tms%2043820#.

(3) New Employees. Within 90 days of entry into the new position, and as part of their new employee orientation, all new employees will complete “Operation S.A.V.E,” VA TMS Course # 66979, https://va-hcm03.ns2cloud.com/learning/user/catalogsearch/catalogSearchDispatchAction.do?searchType=filteredSearch&keywords=tms%2043820#.

(4) New Health Care Providers. Within 90 days of entry into the new position, all new health care providers will complete “Skills Training for Evaluation and Management of Suicide,” VA TMS Course #39351, https://va-hcm03.ns2cloud.com/learning/user/catalogsearch/catalogSearchDispatchAction.do?searchType=filteredSearch&keywords=39351%20#

(5) Lethal Means Safety Training. Upon entry into the associated position, any staff with a reasonable expectation to provide lethal means safety counseling to patients, will complete “Lethal Means Safety Training,” VA TMS Course # 34560, https://va-hcm03.ns2cloud.com/learning/user/catalogsearch/catalogSearchDispatchAction.do?searchType=filteredSearch&keywords=Lethal%20Means%20Safety%20Training#.

(6) Additional Training. Any staff member of VANCHCS can request additional training or consultation regarding Risk ID from the Suicide Prevention team via the e-mail at VHALASMHCSPC@va.gov.

k. Records Management Requirements. All records regardless of format (e.g., paper, electronic, electronic systems) created by this policy shall be managed per the National Archives and Records Administration (NARA) approved records schedules found in VA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Manager or Records Liaison.

4. ASSIGNMENT OF RESPONSIBILITIES

a. Chief of Staff, or Designee. The Chief of Staff, or designee, is responsible for ensuring all VANCHCS staff follow the guidance in this SOP.

b. Service Line Chiefs/Supervisors. The Supervisors/Service Line Chiefs will meet with teams who are identified by Facility Risk ID Champions as who would benefit from additional training and work to develop a corrective action plan to improve any identified deficiencies. Supervisors/Service Line Chiefs will ensure compliance with corrective action plan to address deficiencies.

c. Suicide Prevention Program Manager, or Designee. The Suicide Prevention Program Manager, or designee, is responsible for the implementation, updating and any recessions to this SOP and serves as a resource and reference for Risk ID operations.

(1) Monitoring. Suicide Prevention (SP) Team will monitor CSRE completion daily using a CPRS report that generates at 1430 PST a list of all positive C-SSRSs in the last 24 hours. SP Team will review these charts to confirm that CSRE was attempted or completed and provide assistance when appropriate.

(2) Compliance. In addition, monitoring of compliance will be done using the Risk ID dashboards to track CSRE fallouts, and those provided by OSP on as necessary. Monitoring may include daily monitoring for possible saves, and quarterly reviews for process effectiveness and improvement efforts.

d. VANCHCS Personnel. VANCHCS Personnel are responsible for adherence to VANCHCS policies, procedures and guidelines outlined in this SOP. All areas serving Veterans are responsible for completing the Annual Suicide Screening (C-SSRS), and then completing a warm hand-off for positive screens to an LIP to complete the Comprehensive Suicide Risk Evaluation (CSRE). Responsible areas include, but are not limited to the following: Audiology, Acute Inpatient Psychiatry, Chaplain Services, Community Living Centers/CREC, Complementary & Integrative Health/Move/Whole Health, Emergency Department, Home Based Primary Care, Homeless Program, Interfacility Partners (Environmental Registry, Clinical Resource Hub), Inpatient Medicine, Medicine Specialty Care, Mental Health, Ophthalmology/Optometry, Palliative & Hospice, Primary Care, Rehabilitation and Prosthetic Services, Social Work Service, Surgical Specialty Care, Telephone Ancillary Care Case Management, Urgent Care Clinic, and Women’s Health Services.

e. Facility Risk ID Champions.

(1) Facility Risk ID Champions will monitor adherence to corrective action plan using the Risk ID Power BI Dashboard and Risk ID Monthly Summary Report for VANCHCS and will coordinate with Service Line Chiefs to address any continued deficiencies as identified.

(2) Compliance. Compliance with the Risk ID process will be determined using the Risk ID Power BI Dashboard and Risk ID Monthly Summary Report for VANCHCS. Facility Risk ID Champions will utilize this information to determine what departments would benefit from additional training and will outreach to Supervisors/Service Line Chiefs to notify them of any deficiencies within 30 days of determination.

5. DEFINITIONS

a. Suicide Risk Assessment. Suicide risk assessment is a process in which the healthcare provider gathers clinical information to determine the Veteran’s risk for suicide. The risk for suicide is estimated based on the Veteran’s suicidal thoughts and intent, suicide related behavior, warning signs, risk, and protective factors.

(1) Assessment Components. The assessment must include the minimum of weighing risk factors and protective factors, assigning a level of risk for suicide, proposing a plan of care (such as setting, treatment, education about resources, means restriction, involvement of support, etc.), and obtaining order for 1:1 observation for suicide risk (if indicated).

(2) Documentation. Documentation of a suicide risk assessment is satisfied by either completing the Suicide Risk Evaluation - Comprehensive template, or free text narrative suicide risk assessment that includes the minimum elements as outlined above.

b. Risk Categories. Risk should be stratified into acute and chronic risk. Assignment of risk is divided into three categories along a continuum of risk:

(1) Low Risk. Veteran judged not to be at significant risk for suicide at this time.

(2) Intermediate Risk. Veteran judged to be at increased risk of suicide at this time but not imminently dangerous to self.

(3) High Risk. This is an elevated level of risk at which suicidal behavior is thought likely unless interventions or safety precautions are taken. Providers must make a clinical judgment—based upon risk factors, protective factors, and clinical context—to determine which setting is most appropriate for the Veterans. Settings may include involuntary hold to a locked facility, voluntary admission to an acute psychiatry ward, or outpatient treatment with a level of intensity that is appropriate given the Veteran’s clinical needs.

c. Clinical Judgment. Clinical judgments are algorithms are one of the many data pieces available to providers to assist with making clinical judgments. Since clinical judgment may supersede algorithm-based care, this SOP does not tie a certain risk designation automatically to a “package” of care or imply that it should dictate or limit where a Veteran might receive care. Veterans, particularly suicidal Veterans, are best served by competent providers who weigh risks, ethical implications of decision-making (autonomy vs. beneficence vs. non-maleficence, etc.) and individualized need. Based on the clinical context, there are times when involuntary admission is certainly necessary and other times when risk remains high, but inpatient hospitalization might not be indicated.

d. Facility Risk ID Champions. Facility Risk ID Champions are individuals identified by Suicide Prevention Program Manager who are responsible for ensuring that facilities are aware of updates related to national memorandums, release of educational materials, changes to requirements or guidance documents and any other information related to this initiative.

6. REFERENCES

a. VHA Records Control Schedule 10-1, Medical Assessment Forms: Item Number 6010.3, Psychology Test Data and Worksheet File: Item Number 6400.3, Individual Employee Training Records: Item Number 3400.3, dated January 2021, available at: https://www.va.gov/vhapublications/RCS10/rcs10-1.pdf.

b. VHA Directive 1071(1), Mandatory Suicide Risk and Intervention Training, dated May 11, 2022, amended June 21, 2022, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9789.

c. VHA Handbook 1101.11(4), Coordinated Care for Traveling Veterans, April 22, 2015, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099.

d. VHA Directive 1230, Outpatient Scheduling Process and Procedures, dated June 1, 2022, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9810.

e. VHA Directive 1160.01 Uniform Mental Health Services in VHA Medical Points of Service, dated April 27, 2023, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10280.

f. VHA Directive 1160.07, Suicide Prevention Program, dated May 24, 2021, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9270.

g. VHA Directive 1166, Patient Record Flags, dated November 6, 2023, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=11547.

h. VHA Directive 1605.01, Privacy and Release of Information, dated July 24, 2023, available at: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=11388.

VHA Memorandum 2025-1-7, Suicide Risk Screening and Evaluation Requirements and Implementation Update, available at: https://dvagov.sharepoint.com/:b:/r/sites/ECH/srsa/Shared%20Documents/Risk%20ID/Memos/S%26D%20Memo%20Suicide%20Risk%20Screening%20Risk%20ID%20Update%2012.26.24.pdf?csf=1&web=1&e=8lfOA0.

h. VHA Memorandum 2022-11-23, Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation Update, dated November 23, 2022, available at: https://dvagov.sharepoint.com/:b:/r/sites/ECH/srsa/Shared%20Documents/Risk%20ID/Memos/Archive/11-23-22%20Eliminating%20Veteran%20Suicide%20Suicide%20Risk%20Screening%20and%20Evaluation%20Requirements%20and%20Implementation%20Update%20(Risk%20ID%20Strategy).pdf?csf=1&web=1&e=oNTknV.

i. VHA Memorandum February 2, 2022, Suicide Prevention Program Enhancements: High Risk for Suicide Patient Record Flag Referral Process (HRS-PRF) and Updated Progress Notes (VIEWS 06739759), dated February 2, 2022., available at: https://dvagov.sharepoint.com/:b:/r/sites/VACOMentalHealth/Pubs/ACTIVE%20PUBLICATIONS/20220202_(11)_Suicide_Prevention_Program_Enhancements_HRS-PRF_ocr_pub.pdf?csf=1&web=1&e=eLR3Rs.

NOTE: This is an internal VA Web site that is not available to the public.

j. Suicide Prevention Coordinator Guide, updated December 2022. https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/_layouts/15/viewer.aspx?sourcedoc={e595402b-ffa5-49f0-b2b6-c55d387f564a} NOTE: This is an internal VA Web site that is not available to the public.

Risk Stratification Table, Rocky Mountain MIRECC for Suicide Prevention, available at: https://www.mirecc.va.gov/visn19/trm/.

l. The Joint Commission, National Patient Safety Goal for Suicide Prevention, Current edition. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_18_suicide_prevention_hap_bhc_cah_11_4_19_final1.pdf

m. Department of Defense and Department of Veterans Affairs, VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide, Version 2.0, May 2019, available at: https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf.

n. Deputy Under Secretary for Health for Operations and Management, Eliminating Veteran Suicide: Implementation Update on Suicide Risk Screening and Evaluation (RISK ID Strategy) and the Safety Planning for Emergency Department (SPED) Initiatives, 17 Oct, 2019, available at: https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8564.

7. RESCISSION

SOP-MH-116-45, Suicide Risk identification and Prevention Strategy, dated October 27, 2020, is rescinded.

8. REVIEW

This SOP must be reviewed at minimum at recertification and including when there are changes to the governing document. This review is documented on the VHA Forms and Publications Website (see http://vaww.va.gov/vhapublications/index.cfm).

9. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of March 31, 2030. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

Devin Marsh, Ph.D. Associate Chief of Staff, Mental Health Date Approved: 03/31/2025 NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Emailed to the All Employee VA Northern California Health Care System Email Distribution List March 31, 2025 .SOPs are available at: https://dvagov.sharepoint.com/sites/VHANCal/sop/SitePages/Home.aspx

NOTE: This is an internal VA Web site that is not available to the public.

A-1

Identification Strategy Staff-Specific Guidance

A-1 Identification Strategy Minimum Requirements by Setting

B-1 Columbia Suicide Severity Rating Scale (C-SSRS)

Appendix C

C-1 C-2

Comprehensive Suicide Risk Evaluation (CSRE)

Appendix D

D-2

D-2

Suicide Prevention Staff

If your site’s SPC is unavailable, please feel free to contact any other SPC or Lee Sasse.

Suicide Prevention Group e-mail…use it to reach all of us simultaneously: VHASPCCA-612MACSuicidePreventionTeam@va.gov

VA NorCal HCS Suicide Prevention and REACH VET Program Manager Lee Sasse, LCSW-PIP Cell: 530-551-1408 Lee.Sasse@va.gov

VA Norcal HCS Program Support Assistant (contact to request gun locks and Veteran’s Crisis Line Materials) VACANT-Actively Recruiting (Contact Lee Sasse)

Mather VA Hospital Suicide Prevention Coordinator VACANT-reach out to Lee Sasse or any other SPC.

Sacramento Valley Suicide Prevention Coordinator (McClellan OPC and Sierra Foothills OPC-Auburn) Trent Lear, LCSW, LAC, MAC Cell: 916-539-9919 Trent.Lear@va.gov

East Bay Suicide Prevention Coordinator (Martinez OPC) David Shernoff, LCSW Cell: 925-282-5260 David.Shernoff@va.gov

Rural Suicide Prevention Coordinator (Chico OPC, Redding OPC, Yuba City OPC) Roxanna Kahrel (formerly Zalesny), LCSW Cell: 530-574-1063 roxanna.zalesny@va.gov

Fairfield/Mare Island Suicide Prevention Coordinator Orise (Shay) Carey. LCSW Cell: 925-862-3204 Orise.Carey@va.gov

Stockton/Modesto/Sonora Suicide Prevention Coordinator Brianna Belcher, LCSW Cell: 916-281-8551 brianna.belcher@va.gov

Appendix E

E-2

E-2

Codes and Service Areas

Appendix F

F-2

F-2

PCMHI Cross Site Coverage Procedures by Site

· Please note the following:

· The information applies to PACT staff (i.e., individuals who are aligned under the Primary Service

· Emergent medication concerns should be seen in Urgent Care or Emergency Departments. There are no emergent med services available in PCMHI.

General Nor Cal Flow

G-2

G-4

Department of Veterans Affairs (VA) Suicide Risk Identification Strategy

SBOR

Suicide Behavior and Overdose Report Use this template to report both drug overdoses and suicidal behaviors, specifically:

1. Behaviors with suicidal or undetermined intent. (For this note template, suicidal ideation is not considered a behavior; only behaviors, including preparatory behaviors, should be reported.)

1. Any overdoses, including accidental, intentional, and adverse effect overdoses.

Only one event at a time can be reported within this template. If the patient reports multiple events that have not already been reported, please do the following:

1. Enter the first event in the SBOR template

2. For the second event that needs to be reported, create a new historical visit.

3. Within that new historical visit, enter an SBOR note for the second event Repeat steps 2 and 3 for any additional events that need to be reported.

*Date of event (enter as MM/DD/YYYY e.g., 01/15/2019): ___________________________

· Date is approximate

Person(s) reporting information: (Select all that apply.)

· Self-report

· Family member: ____________________________

· Outside agent: ____________________________

· VA staff: ______________________________

· Other: ________________________________

*Event Type Being Reported (Select only one.)

· Non-Suicidal Overdose Event [skip to Reported Patient Status]

· Accidental overdose

· Severe adverse effect (i.e., patient took medication as prescribed, with significant side effect such as severe somnolence or confusion; could be due to medication interaction)

· Suicidal behavior, OR possible suicidal behavior with unknown intent (including suicidal overdose events) [If yes, answer the following questions]:

*Did Veteran have suicidal intent for this event?

· Yes

· Unknown to author

*Was the behavior being reported preparatory only?

Preparatory Behavior: Acts or preparation towards engaging in Suicidal Self-Directed Violence, but before potential for injury has begun.

Examples of preparatory behaviors include practicing with an unloaded firearm, stockpiling medications, writing a suicide note.

· No

· Yes

· Unknown to author

*Did the event reportedly result in injury?

Injury: damage or harm done to the body caused by external force.

· No

· Yes. Description of injury*: ____________________________________________

· Unknown to author

Was treatment plan modified because of the event?

· No

· Yes _________________________________________________________________

· Unknown to author

*Reported patient status at time of event:

· Outpatient

· Inpatient

· Mental Health Residential Rehabilitation Treatment Program (RRTP)

· VA Community Living Center (CLC)

· VA Contracted Community Residential or Transitional Bed

· Other: ____________________________________________________________

· Unknown to author

*Did this event reportedly occur on VA property?

· No

· Yes Reminder: If this event involved suicidal or undetermined intent, you must directly notify the Suicide Prevention team and supervisor, by phone or IM, to initiate mandated reporting within 1 hour.

· Unknown to author

*Did the event reportedly occur within 7 days of discharge from a VA inpatient or residential care facility?

· No

· Yes Reminder: If this event involved suicidal or undetermined intent, you must directly notify the Suicide Prevention team and supervisor, by phone or IM, to initiate mandated reporting within 1 hour.

· Unknown to author

*Was the event reportedly interrupted?

Interrupted by self or other is defined as: a person takes steps to injure self but is stopped by self/another person prior to fatal injury. The interruption may occur at any point.

In the case of overdose, naloxone administration counts as an interruption.

· No

· Yes, by self. Explain: ________________________________________________________

· Yes, by other. Explain: ________________________________________________________

· Unknown to author

*Reported outcome of event (Select all that apply).

· Died

· Hospitalization ________________________________________________________

· Remained outpatient

· Other ________________________________________________________

· Unknown to author

*Method(s) used for this event (Select all that apply.)

· Unknown to author

· Not applicable – event was preparatory only with no method(s) involved

· Event reported as:

· Overdose (Select all that apply.) [if not reporting an overdose, skip to other method types]

· Acetaminophen/Other NSAIDS

· Alcohol

· Amphetamine/other psychostimulants

· Anticonvulsants (click to expand)

· Barbiturates

· Gabapentin/Pregabalin

· Other anticonvulsants: ____________________________________________

· Unknown anticonvulsants

· Antidepressants (click to expand)

· Tricyclic Antidepressants (e.g. amitriptyline, amoxapine, clomipramine, desipramine, imipramine, trimipramine, doxepin, maprotiline, protriptyline)

· SSRIs (e.g. citalopram, fluoxetine, fluvoxamine, escitalopram, paroxetine, sertraline, vilazodone, asenapine)

· SNRIs (e.g. duloxetine, venlafaxine, desvenlafaxine, Levomilnacipran, milnacipran)

· Atypical Antidepressants (e.g. bupropion, mirtazapine, trazodone, vortioxetine, nefazodone)

· MAO Inhibitors (phenelzine, tranylcypromine, isocarboxazid, selegiline)

· Other antidepressants: ____________________________________________

· Unknown antidepressants

· Antihistamines (click to expand)

· Diphenhydramine/Hydroxyzine

· Other antihistamine: ____________________________________________

· Unknown antihistamines

· Antipsychotics (click to expand)

· Typical Antipsychotics (e.g. chlorpromazine, fluphenazine, haloperidol, loxapine, molindone, perphenazine, pimozide, thioridazine, thiothixene, trifluoperazine)

· Atypical antipsychotics (e.g. aripiprazole, olanzapine, lurasidone, paliperidone, risperidone, quetiapine, ziprasidone)

· Clozapine

· Other antipsychotics: ____________________________________________

· Unknown antipsychotics

· Benzodiazepines (click to expand)

· Alprazolam/Lorazepam/Diazepam

· Chlordiazepoxide

· Clonazepam

· Estazolam/Flurazepam/Temazepam/Oxazepam

· Midazolam

· Other benzodiazepine: ____________________________________________

· Unknown benzodiazepines

· Non-Benzodiazepine sedatives/hypnotics (click to expand)

· Eszopliclone

· Ramelteon

· Zolpidem

· Zaleplon

· Other sedatives/hypnotics: ____________________________________________

· Unknown sedatives/hypnotics

· Cannabis

· Central Muscle Relaxants (click to expand)

· Baclofen

· Cyclobenzaprine

· Metaxalone

· Methocarbamol/Carisoprodol

· Tizanidine

· Other central muscle relaxants: ____________________________________________

· Unknown central muscle relaxants

· Cocaine (click to expand)

· Mood Stabilizers (click to expand)

· Carbamazepine

· Divalproex/valproate/valproic acid

· Lamotrigine

· Lithium

· Other mood stabilizer: ____________________________________________

· Unknown mood stabilizers

· Prescription Opioids (click to expand)

· Fentanyl

· Hydrocodone

· Methadone

· Morphine

· Oxycodone Suboxone, Subutex, Buprenorphine

· Other prescription opioids: ____________________________________________

· Unknown prescription opioids

· Non-Prescription Opioids (click to expand)

· Heroin

· Carfentanil

· Illicitly manufactured fentanyl

· Other non-prescription opioids: _________________________________________

· Unknown non-prescription opioids

· Other/Non-opioid/Non CNS pharmaceuticals other than listed above (click to expand)

· Antihypertensive

· Anticoagulants

· Antidiabetic agents (e.g., insulin)

· Other: ________________________________________________________

· Unknown to author

*Was naloxone reported to be administered to the patient? [if No or Unknown, skip to page 6]

· Unknown to author

· No

· Yes

Which were the sources of naloxone that were reportedly administered to the patient? (Select all that apply.)

· Patient’s outpatient naloxone prescription

· Other lay person’s naloxone

· VA facility-stocked naloxone (including VA Police)

· Emergency Department/Urgent Care Center (ED/UCC)

· Mental Health Residential Rehabilitation Treatment Program (MH RRTP)

· Outpatient Clinic/Community Based Outpatient Clinic (CBOC)

· Automated External Defibrillator (AED) cabinet

· VA Police

· Other VA facility-stocked naloxone (specify)

· Non-VA services naloxone (specify, e.g., Emergency Medical Services, Fire Department)

· Other (specify): ____________________________________________

Approximate date naloxone was reportedly used (enter as MM/DD/YYYY e.g., 02/01/2017): _________________________________________________

Naloxone was reportedly administered by:

· Self (patient)

· VA facility staff (including VA Police) Comment: _____________________________

· Layperson bystander

· Non-VA emergency responder

· Other: ____________________________________________ Declined to answer

Number of naloxone doses administered? (e.g., one nasal spray = 1 dose)

· 1

· 2

· 3

· 4

· 5+

· Unknown

What was the reported outcome of the naloxone use?

· The patient survived

· The patient died

· Unknown

· Other: ____________________________________________

Are there any negative consequences reported in relation to the naloxone use/overdose event?

· Falls

· Arrest/incarceration of patient

· Arrest/incarceration of person administering naloxone or bystander

· Issues with the police/paramedics/fire department Comment:_________________

· Anger

· Other (specify): ____________________________________________

· Unknown: ____________________________________________

· None

· Additional Comments: ____________________________________________

· THIS SECTION TO BE COMPLETED BY PATIENT’S TREATMENT PROVIDER

Click checkbox above to expand section if you are patient’s treatment provider; if not patient’s treatment provider, continue to Overdose Prevention Education below [skip to Overdose Prevention]

· What risk factors are present that could increase the risk of overdose?

· Previous overdose Comment: __________________________________________

· Discuss circumstances surrounding current and previous overdoses to identify potential patters and ways to mitigate risk and improve patient safety Periods of abstinence from opioids (e.g., detoxification, inpatient or residential treatment, incarceration)

· Discuss how periods of abstinence can decrease tolerance and increase risk for overdose as well as strategies to decrease risk, including medication for opioid use disorder.

· Opioid tapering

· Discuss how opioid tapering can decrease tolerance and increase risk for overdose as well as strategies to decrease risk (e.g., slow taper, consideration of Opioid Use Disorder diagnosis and treatment)

· Substance use disorder (SUD)/substance misuse (including opioid use disorder and alcohol use disorder) Plan: Discuss substance misuse and offered SUD treatment, including Medication for Opioid Use Disorder and Alcohol Use Disorder, and counseling

· Substance misuse/SUD being addressed in treatment plan

· Referral for SUD treatment

· Initiated medication for SUD Specify: ________________________________

· Discussed with the patient and the patient refuses substance use or SUD treatment/referral

· Mental health (e.g., PTSD, depression, anxiety, schizophrenia, bipolar disorder) Comment: ____________________________________________

· Mental health being addressed in treatment plan Referral for mental health treatment

· Discussed with the patient and the patient refuses mental health treatment/referral

· Use of Sedatives (e.g., benzodiazepines) Comment: _______________________

· Discuss risk associated with use of sedatives

· Discuss alternative treatments

· Discuss tapering/discontinuation

· Unmet pain management needs

· Patient scheduled for follow-up to address pain management needs

· Patient declined follow-up for pain management needs at this time

· Use of non-prescribed opioids

· Discuss risks associated with use of non-prescribed opioids and ways to mitigate risk and improve patient safety

· Use of prescribed opioids

· Opioids prescribed only from the VA

· Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

· Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

· Consider non-opioid treatments for pain

· Change in opioid treatment plan

· Slow taper (e.g., 5-20% reduction every 4 weeks; see Opioid Taper Decision Tool) Other: ________________________________________

· No change in opioid treatment plan

· Opioids prescribed only from non-VA sources

· Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

· Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

· Discuss overdose with outside provider and ways to improve patient safety

· Consider non-opioid treatments for pain

· Opioids prescribed from both VA and non-VA sources

· Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

· Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

· Discuss overdose with outside provider and ways to improve patient safety

· Review consent for long term opioid therapy with the patient

· Consider non-opioid treatments for pain

· Change in opioid treatment plan

· Slow taper (e.g., 5-20% reduction every 4 weeks; see Opioid Taper Decision Tool)

· Other: ________________________________________

· No change in opioid treatment plan

· Medical – (e.g., sleep disordered breathing, renal disease, pulmonary disease, liver disease) Comment: _______________________________________

· History of falls

· Emergency department visits

· History of HIV

· Homelessness

· Family stressors

· Financial concerns and unemployment

· Other Comment: ____________________________________________

· *What changes to the patient’s treatment plan were enacted based on the overdose event and/or use of naloxone?

H-1 H-2

· Referral *Does the patient need immediate care?

· Yes

· Warm handoff to PCMHI or Mental Health team

· Escort to emergency department

· Other: ____________________________________________

· No

· Refer to primary care provider

· Refer to PCMHI or mental health provider

· Refer to substance use disorder (SUD) provider

· Refer to pain specialist

· Other: ____________________________________________

· None

· Patient declined referral

· Additional comments: ____________________________________________

*Overdose Prevention Education (select one)

· Education could not be provided (e.g., outside scope of practice, or patient/caregiver was not present). Skip to Naloxone Prescription.

· Education provided: (if selected, continue to the remaining questions in this section)

Prescriber and/or trained clinical staff discussed overdose prevention and, among patients with opioid overdose, reinforced opioid overdose prevention, recognition, and response education and naloxone use and disposal (e.g., by providing and reviewing VA pamphlets below).

For patients with opioid overdose, because patient is still at risk for overdose, a new naloxone prescription is recommended as well as training/education of potential bystanders on signs/symptoms of opioid overdose.

For patients with suicidal overdose, discussion of access to lethal means and safety planning are recommended.

Education…