D.15 Management of Suicide Risk Policy, 36C25522R0052.pdf

Management of Suicidal Risk Policy

SOP BH-53

Harry S Truman Veterans’ Hospital Columbia, MO 65201

Signatory Authority:

Cheryl Hemme, M.D., Behavioral Health Chief

Responsible Owner:

Behavioral Health Chief

Service Line(s):

Behavioral Health

Effective Date:

January 5, 2021

Recertification Date:

January 5, 2026

1. PURPOSE AND AUTHORITY

a. This standard operating procedure (SOP) establishes policies and procedures for treatment planning regarding the management of suicidal risk.

2. PROCEDURES

a. Suicide Prevention Team:

(1) Responds to referrals from staff members, the Veterans Crisis Line (VCL), and other touch points to ensure that provider are education and assisted to provide response to at-risk Veterans to receive immediately care and services. SPCs play an integral role in providing direct support to Veterans while fulfilling key outreach and training responsibilities as part of VA’s public health model. Serving as subject matter experts for all matters related to preventing Veteran suicide, SPCs are responsible for identifying, coordinating case managing, and supporting high risk Veterans within facilities and coordinating strategies to increase the awareness and adoption of suicide prevention best practices within the community.

(2) Serving as facility subject matter experts (SMEs) and points of contact (POCs) for matters related to suicide, including prevention, intervention, postvention efforts, education and outreach, and suicide behavior and death reporting; collaborating with other SPCs and VA at-large to share best practices through multiple touch points;

accurately documenting services rendered to improve the SPP overall.

(3) Ensuring reporting mechanisms are implemented for all suicidal behaviors occurring within facility catchment areas; managing the Patient Record Flag Category 1

– High Risk for Suicide (HRS-PRF) process for all Veterans determined to be at a high risk for suicide; reviewing the nature of care provided using a variety of tracking and reporting tools.

(4) Responding to referrals from staff members, the Veterans Crisis Line (VCL), and other touch points to ensure that at-risk Veterans immediately receive care and services.

(5) Participating in suicide prevention outreach activities by distributing promotional materials, engaging with stakeholders at event awareness tables, and engaging with high-risk Veterans via the Caring Communication Program; working with Public Affairs Officers (PAOs) to encourage reporters to use safe messaging; providing VA S.A.V.E.

and other gatekeeper training to community members.

D.15 Management of Suicide Risk Policy, 36C25522R0052

January 5, 2021 SOP BH-53

(6) Training both clinical and nonclinical staff within VA to identify and respond to Veterans who are at increased risk for suicide; providing training to community organizations and staff who have contact with Veterans

b. Practitioners within the BHSL will maintain keen awareness for the high-risk factor of suicide in their psychiatric diagnoses. Specifically, depression, substance abuse, and psychosis are the three psychiatric diagnoses which have the highest probability of suicide. Practitioners will recognize that, in combination, these three psychiatric diagnoses require particularly close monitoring with regard to possible suicide.

c. Practitioners within the BHSL will remain alert to the following personalized risk factors for suicide: current ideation, intent, plan; age (elderly); Caucasian race; male gender; feelings of hopelessness; impulsiveness; general health problems; living alone; recent loss of family member/loved one; history of abuse; access to firearms; a history of prior suicide attempts; a family history of suicide attempts; and personal and/or a family history of substance abuse.

d. When working with patients who are at high risk for suicide, appropriate and reasonable strategies will be used to prevent self-injurious behavior and ensure that personalized protective factors are present, including (but not limited to) the following:

(1) assignment to the proper level of care

(2) recommendations for appropriately close observation by caregivers, family, and significant others

(3) proactive efforts to limit access to firearms and/or other potentially lethal objects

(4) affirmation in religious beliefs if applicable

(5) instilling a sense of responsibility and personal worth in the patient

(6) notification of law enforcement officials if there appears to be an immediate danger of harm to self or others.

e. In all cases, documentation of the precautions taken to prevent suicide or self-injurious behavior will be highly detailed. Specifically, instructions to patients, family members, and significant others regarding the restriction of access to firearms and other potentially lethal objects will be consistently documented.

f. Practitioners are responsible to report all suicide attempts to the Suicide Prevention Coordinator for inpatients and outpatients. In addition, practitioner responsibilities for inpatients are:

(1) Complete personalized protective/risk factors, Suicide Behavior and Overdose Report, and document "Safety Plan" copy provided to patient.

(2) Schedule follow-up within 7 days of discharge and weekly appointments for 4 weeks thereafter.

(3) Ensure plan of care is addressed.

(4) Practitioner responsibilities for outpatients in addition to notification of Suicide Prevention

Coordinator are:

(a) Notify Suicide Prevention Coordinator of missed appointments.

(b) Notify Suicide Prevention Coordinator if the patient makes a suicide attempt at or outside of the hospital.

(c) Notify the Suicide Prevention Coordinator if the veteran becomes high risk.

(d) Ensure the plan of care is addressed.

(e) Identify a family member or friend and a valid telephone number.

g. For patients experiencing chronic suicidal ideations; practitioners should notify the

Suicide Prevention Coordinator if extreme changes are noted in severity of ideations and/or intent, and extreme changes in personalized risk factors or protective factors.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Suicide Prevent Coordinator will collaborate with staff for:

(1) Tracking and reporting on Veterans who have attempted suicide or are at high risk for suicide

(2) Responding to referrals from the Veterans Crisis Line (VCL) and self-referrals from other sources

(3) Ensuring that all VA staff members have received discipline-appropriate suicide prevention training (VA S.A.V.E. training or equivalent)

(4) Collaborating with community organizations and partners to increase awareness of suicide prevention best practices and providing training to individuals who have contact with Veterans

(5) Providing general consultation to providers on available resources for suicidal individuals, as well as expertise and direction in the areas of system design to prevent deaths by suicide within their local VA medical centers

(6) Working with providers to ensure that monitoring and treatment is intensified for high-risk patients while making sure that those who are at elevated risk receive education and support about approaches to reduce risks

(7) Reporting to OMHSP on Veterans who attempted or died by suicide and sending OMHSP requested data, which is used to determine characteristics and risks associated with these groups of Veterans

(8) Making sure that providers follow up on missed appointments to ensure patient safety for high-risk patients and initiate problem-solving decisions about possible tensions or difficulties in patients’ ongoing care

(9) Ensuring that medical centers have established a High-Risk for Suicide List (HRSL) of Veterans and a process for establishing Patient Record Flag Category 1 – High Risk for Suicide (HRS-PRFs), which includes:

(a) Exclusively controlling all HRS-PRFs and limiting their use to patients who meet the criteria for being placed on the facility HRSL

(b) Coordinating with facility committees that manage PRFs to incorporate the use of HRS- PRFs into overall facility flag processes

(c) Assessing the risk for suicide in individual patients in collaboration with their treating clinicians and ensuring that those patients receive appropriate follow-up care for any missed mental health appointments

(d) Establishing a system of reviewing HRS-PRFs at least every 90 days

(e) Documenting, when appropriate, the nature of the follow-up care and plans for continuing treatment in the electronic health record (EHR)

(f) Identifying training needs related to suicide prevention

(g) Maintaining communication with the facility-designated advisory groups to keep them aware of flag placements and review outcomes

4. DEFINITIONS

a. None

5. REFERENCES

a. Practice Guideline for Major Depressive Disorder in Adults: American Psychiatric Association, 1993.

b. VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide.

c. VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.

6. RECISSIONS

a. BHSL SOP BHSL SOP 09-05, Management of Suicidal Risk Policy

7. REVIEW

This SOP must be reviewed, at a minimum of 5 years at recertification, when there are changes to the governing document, and any regulatory requirements for more frequent review.

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of January 5, 2026.

In the event of contradiction with national policy, the national policy supersedes and controls.

9. SIGNATORY AUTHORITY

CHERYL HEMME, M.D.

Behavioral Health Chief NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at:

https://dvagov.sharepoint.com/sites/vhacmo/pnp/default.aspx Note: This is an internal VA Web site that is not available to the public.

Hemme, Cheryl A.

Digitally signed by Hemme, Cheryl A.

Date: 2021.03.18 15:13:21 -05'00'