D.15- PROVISION OF SUICIDE PREVENTION SCREENINGS AND SAFETY PLANS IN AMBULATORY CARE SETTINGS- MAR 2023.pdf
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- Solicitation number
- 36C24224R0049
About this file
This document is a Standard Operating Procedure (SOP) from the Syracuse VA Medical Center that establishes procedures for providing suicide prevention screenings and safety plans in ambulatory care settings. It outlines the requirement for all veterans receiving care to be annually screened using the Columbia Suicide Severity Rating Scale (C-SSRS), as well as setting-specific requirements for the C-SSRS in locations like the Community Living Center, Emergency Department, and outpatient clinics. The SOP provides detailed procedures for completing a Comprehensive Suicide Risk Evaluation and developing safety plans in response to positive screenings. It also discusses expectations for using the Risk ID Power BI Dashboard to monitor clinic-level data and identify missed screening opportunities.
The related federal contract opportunity is a Request for Proposal (RFP) for a Community Based Outpatient Clinic (CBOC) to provide primary care services to veterans in Cayuga County, New York. The contract will cover a base year with nine one-year option periods. This is an unrestricted procurement under NAICS code 621498 (All Other Outpatient Care Centers) with a size standard of $25.5 million. The solicitation number is 36C24224R0049 and the opportunity is being issued by the Department of Veterans Affairs, Veterans Integrated Service Network 2.
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PROVISION OF SUICIDE PREVENTION SCREENINGS & SAFETY PLANS IN
AMBULATORY CARE SETTINGS
SOP 528a7-116-054
Syracuse VA Medical Center Syracuse, NY 13210
Signatory Authority:
Associate Chief of Staff for Mental Health
Responsible Owner:
Suicide Prevention Coordinator
Service Line:
Mental Health
Effective Date:
March 2023
Recertification Date:
March 2028
1. PURPOSE AND JUSTIFICATION
a. The purpose of this standard operating procedure (SOP) is to establish Syracuse VA Medical Center (SVAMC) procedures on the provision of Suicide Prevention Screenings in Ambulatory Care settings throughout the medical center. This SOP must be followed by all Syracuse VAMC personnel.
b. This SOP sets forth mandatory procedures and processes to ensure compliance with VA Memorandum, Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation (Risk ID Strategy), dated November 13, 2020.
2. SUMMARY OF CHANGES
a. SOP number updated from 528a7-116-053 to 528a7-116-054. Rehab Ophthalmology section updated.
3. PROCEDURES
a. Universal Screening Requirement.
(1) All Veterans receiving care from the Syracuse VA Medical Center should be screened annually with the Columbia Suicide Severity Rating Scale (C-SSRS).
(a) This annual requirement will be managed through the Electronic Medical Record (EMR), Clinical Reminder system.
(2) Completion of this C-SSRS clinical reminder should be facilitated during any scheduled encounter with a Veteran in an ambulatory care setting, by an appropriate staff member.
March 2023 SOP 528a7-116-054
(a) A list of provider/disciplines authorized to complete the C-SSRS can be found in the OMHSP Staff Specific Guidance Matrix. NOTE: This is an internal VA website that is not available to the public.
(3) Associate Chief of Staff, Supervisors, Team Leads and Program Managers will be responsible for ensuring the completion of the C-SSRS.
b. Setting Specific Requirements. In addition to the annual C-SSRS clinical reminder, there are site specific requirements for completion of a C-SSRS.
(1) Staff will follow procedures identified within this SOP for the management of positive C-SSRS screeners in these locations.
(2) Community Living Center (CLC).
(a) The C-SSRS will be completed withing 24 hours of admission and within 24 hours prior to discharge.
(3) Emergency Department (ED).
(a) The C-SSRS will be completed at each encounter. The C-SSRS is embedded in the “ED NURSING TRIAGE NOTE” within the EMR.
(4) Inpatient Medical/Surgical.
(a) The C-SSRS will be completed within 24 hours of admission and within 24 hours prior to discharge.
(5) Inpatient Mental Health.
(a) The C-SSRS will be completed within 24 hours of admission and within 24 hours prior to discharge.
(6) Outpatient Mental Health.
(a) The C-SSRS will be completed during any intake evaluation and then as clinically indicated throughout the course of treatment.
(7) Pain Clinic.
(a) The C-SSRS must be completed at the time of referral to the Pain Clinic.
1. In addition, if it has been greater than 30 days since the time of referral, the C- SSRS must be completed during the intake.
(b) The C-SSRS should be administered throughout the course of treatment as clinically indicated thereafter.
(8) Sleep Clinic.
(a) The C-SSRS must be completed at the time of referral to the Pain Clinic.
1. In addition, if it has been greater than 30 days since the time of referral, the C- SSRS must be completed during the intake.
2. The C-SSRS should be administered throughout the course of treatment as clinically indicated thereafter.
c. Completion of Comprehensive Suicide Risk Evaluation (CSRE) in response to positive C-SSRS.
(1) In the event of a positive C-SSRS screening in an outpatient setting, all staff are required to ensure the completion of a CSRE by a Licensed Independent Provider (LIP) on the same calendar day.
(2) In the event of a positive C-SSRS in the ED or inpatient setting, the CSRE must be completed by an LIP within 24 hours or prior to discharge home, whichever comes first.
(3) A complete list of disciplines authored to complete the CSRE can be found in the OMHSP Staff Specific Guidance Matrix. NOTE: This is an internal VA website that is not available to the public.
(4) The subsection below will identify the procedures in place for the completion of CSREs for each facility section.
(5) Audiology.
(a) Providers assigned to Audiology who complete a positive C-SSRS, will contact Primary Care Mental Health Integration (PCMHI) via dedicated Microsoft Teams channel.
(b) Audiology and PCMHI will coordinate the warm hand off for the completion of the
CSRE.
(c) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
(d) If not a crisis situation, staff will coordinate with PCMHI via Microsoft Teams to schedule a follow up appointment to complete the CSRE the same calendar day.
(6) Caregiver Support.
(a) If the C-SSRS is positive Caregiver Support staff will complete CSRE the same day.
(b) Negative CSRE. Low acute, low chronic.
1. Caregiver support staff will complete the safety plan with the Veterans.
a. In addition, staff will offer the Veteran referral to Mental Health if clinically appropriate.
(c) Positive CSRE. Intermediate or high acute, intermediate, or high chronic.
1. Caregiver support staff will complete the Suicide Prevention consult within Computerized Patient Record System (CPRS) to alert the Suicide Prevention Team.
a. Staff will then alert the rest of the Caregiver Support Team.
2. In addition, staff will complete safety plan with the Veteran and document in the Electronic Medical Record (EMR).
(7) Home Based Primary Care.
(a) All LIP’s will be expected to complete a CSRE and Safety Plan with a Veteran testing positive on their C-SSRS.
(b) If the provider completing the C-SSRS is not an identified LIP, a warm hand off will be completed to an LIP within their service.
(8) Homeless Program.
(a) All LIP’s will be expected to complete a CSRE and Safety Plan with a Veteran testing positive on their C-SSRS. If the provider completing the C-SSRS is not an identified LIP, a warm hand off will be completed to an LIP within their service.
(9) Medicine Specialty Care.
(a) Providers assigned to Medicine Specialty Care who complete a positive C-SSRS, will contact PCMHI via dedicated Microsoft Teams channel. NOTE:
Ophthalmology/Optometry and PCMHI will coordinate the warm hand off for the completion of the CSRE.
(b) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
2. If not a crisis situation, PCMHI staff will coordinate scheduling with Veteran to complete the CSRE the same calendar day.
(10) Mental Health.
(a) All LIP’s will be expected to complete a CSRE and Safety Plan with a Veteran testing positive on their C-SSRS.
1. If the provider completing the C-SSRS is not an identified LIP, a warm hand off will be completed to an LIP within their service.
2. If an LIP is not available or accessible, provider will utilize the mental health walk in clinic provider for a warm handoff.
(11) Ophthalmology/Optometry.
(a) Providers assigned to Ophthalmology/Optometry who complete a positive C- SSRS, will contact PCMHI via dedicated Microsoft Teams channel.
1. Ophthalmology/Optometry and PCMHI will coordinate the warm hand off for the completion of the CSRE.
(b) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
2. If not a crisis situation, staff will coordinate with PCMHI via Microsoft Teams to schedule a follow up appointment to complete the CSRE the same calendar day.
(12) Primary Care Mental Health.
(a) All LIP’s within PCMHI will be expected to complete a CSRE and Safety Plan with a Veteran testing positive on their C-SSRS.
(13) Primary Care.
(a) Any LIP completing the C-SSRS which is positive, will complete the CSRE or ensure a warm hand off takes place with PCMHI prior to the Veteran leaving the clinic.
(b) Nursing assigned to Primary Care who complete a positive C-SSRS, will contact PCMHI to coordinate the warm hand off for the completion of the CSRE prior to the Veteran leaving the clinic.
(14) Rehabilitation and Prosthetic Services.
(a) Any LIP completing the C-SSRS which is positive, will complete the CSRE or ensure a warm hand off takes place with PCMHI prior to the Veteran leaving the clinic.
(b) Non-LIP Providers assigned to Rehabilitation and Prosthetic Services who complete a positive C-SSRS, will contact PCMHI via dedicated Microsoft Teams channel.
(c) Rehabilitation and Prosthetic Service and PCMHI will coordinate the warm hand off for the completion of the CSRE.
(d) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
2. If not a crisis situation, staff will coordinate with PCMHI via Microsoft Teams to schedule a follow up appointment to complete the CSRE same calendar day.
(15) Whole Health/Center for Integrated Health (CIH).
(a) Providers assigned to Whole Health who complete a positive C-SSRS, will contact Primary Care Mental Health (PCMHI) via dedicated Microsoft Teams channel.
(b) Whole Health and PCMHI will coordinate the warm hand off for the completion of the CSRE.
(c) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
2. If not a crisis situation, staff will coordinate with PCMHI via Microsoft Teams to schedule a follow up appointment to complete the CSRE same calendar day.
(16) Women’s Health Services.
(a) Any LIP completing the C-SSRS which is positive, will complete the CSRE or ensure a warm hand off takes place with PCMHI prior to the Veteran leaving the clinic.
(b) Nursing assigned to Primary Care who complete a positive C-SSRS, will contact Primary Care Mental Health (PCMHI) to coordinate the warm hand off for the completion of the CSRE prior to the Veteran leaving the clinic.
(c) If PCMHI Unavailable.
1. If in Crisis, follow local procedure for escorting (or transporting) a Veteran to the Emergency Room.
2. If not a crisis situation, staff will coordinate with PCMHI via Microsoft Teams to schedule a follow up appointment to complete the CSRE with same calendar day.
d. Completion of Safety Plans in Response to CSRE. It is expected in all settings where a CSRE is completed, a Safety Plan will be completed and documented in the EMR with the “Suicide Prevention Safety Plan” note title.
(1) Veteran has an active Safety Plan in EMR.
(a) If there is an active Safety Plan in the EMR that was completed in the previous 6 months, the provider will complete a thorough review of the Safety Plan with the Veteran and document this in the EMR through the “Suicide Prevention Safety Plan Review/Decline” note title.
(2) Veteran refuses/declines Safety Plan.
(a) If the Veteran refuses or declines to complete the Safety Plan, provider will document this in the EMR through the “Suicide Prevention Safety Plan Review/Decline” note title.
e. Risk ID Power BI Dashboard: C-SSRS Clinic-Level Data & Future Appointment Reports Guidance. Expectations for use of this dashboard are outlined below. Additional information on the components of the dashboard and instructions for use can be found here. NOTE: This is an internal VA website that is not available to the public.
(1) Report Utilization
(a) Use of the Risk ID Dashboard provides Service Chiefs, Mangers, and Service Level Personnel with information related to missed opportunities and future opportunities from completion of required C-SSRS clinical reminders. NOTE: This is an internal VA website that is not available to the public.
(b) Service Chiefs.
1. Use of the dashboard is intended to provide awareness as to how clinics within their service line are performing on the provision of the C-SSRS clinical reminder. This information can also be used to help identify barriers, process improvement opportunities and best practices.
(c) Managers.
1. Managers should have more of an active role in the monitoring of their clinics’ performance on the provision of the C-SSRS clinical reminder.
2. Mangers should work with their staff to develop sustainable practices which eliminate or reduce barriers in support of OMHSP target of 100% completion rates.
3. Mangers will coordinate with Suicide Prevention to assist with any education and training needs in the provision of the C-SSRS or the use of the Risk ID Power BI Dashboard.
(d) Service Level Personnel.
1. Providers in positions of direct patient services are expected to monitor the dashboard regularly to identity Veterans who are scheduled in their clinics with the clinical reminder for suicide screening is due.
(e) Suicide Prevention Coordinator/Program Manager.
1. The Suicide Prevention Coordinator/Program Manager will monitor the dashboard and provide weekly updates to Mental Health Associate Chief of Staff
(ACOS).
4. ASSIGNMENT OF RESPONSIBILITIES
a. Service Chief. The Service Chief is responsible for:
(1) Communicating this SOP and any changes to all appropriate staff.
(2) Reviewing and ensuring all appropriate changes are made to this SOP.
(3) Ensuring all information contained herein follows any, and all governing guidance where appropriate.
(4) Ensuring all appropriate staff adhere to this SOP.
b. All Other Staff. All Other Staff are responsible for:
(1) Adhering to this SOP.
5. DEFINITIONS
a. Columbia Suicide Severity Rating Scale (C-SSRS). Evidence based suicide screening tool, adopted by the VA as a gold standard to Suicide Risk Screening. The instrument contains 8 question items and is scored by the EMR. A printable copy of the C-SSRS can be located here. NOTE: This is an internal VA website that is not available to the public.
b. Comprehensive Suicide Risk Evaluation (CSRE). A comprehensive tool developed by the VA to further assess and stratify the Veterans overall suicide risk at both acute and chronic levels. A printable copy of the CSRE can be located here.
NOTE: This is an internal VA website that is not available to the public.
6. REFERENCES
a. VA Memorandum, Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation(Risk ID Strategy), dated November 13, 2020. NOTE: This is an internal VA website that is not available to the public.
b. Suicide Risk Identification and Management - Risk_ID_Power_BI_Dashboard_C- SSRS_Clinic-Level_ Data_and_Future_Appointments_Report Guidance.pdf - All Documents (sharepoint.com). NOTE: This is an internal VA website that is not available to the public.
c. OMHSP Staff Specific Guidance Matrix. NOTE: This is an internal VA website that is not available to the public.
7. REVIEW
At minimum at recertification, when there are changes to the governing document (for example, national policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review.
8. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of March 2028. In the event of contradiction with national policy, the national policy supersedes and controls.
9. SIGNATORY AUTHORITY
LAUREN LOVE-DUBEAU, LCSW-R
Associate Chief of Staff for Mental Health Syracuse VA Medical Center Date Approved: March 16, 2023
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: SOPs are available at: Syracuse Medical Center Document Control SharePoint (DCS). https://dvagov.sharepoint.com/sites/VHASYR/svdc. NOTE: This is an internal VA website that is not available to the public.
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