D.23 PC-15 MANAGEMENT OF SUICIDAL VETERANS (Prevention).pdf

Butler VA Health Care System Medical Center Memorandum PC-15 Butler, PA October 28, 2019

MANAGEMENT OF SUICIDAL VETERANS

I. PURPOSE: To delineate policies, responsibilities, procedures, and guidelines for mitigating the risk of suicide through screening and follow up.

II. POLICY:

A. Any Veteran who presents to or calls Butler VA Health Care System or a Community Based Outpatient Clinic (CBOC) with a primary complaint of an emotional or behavioral need will be screened for suicide risk.

B. Any Veteran who screens positive for suicide risk will be further assessed by a qualifying provider (See Attachment A) on the same day.

C. Veterans who are categorized as high risk for suicide will be identified with a Category I Suicide Risk Flag.

D. The facility will provide support for Veterans who are deemed to be at high risk for suicide and will advise and educate staff concerning suicide prevention strategies for individual Veterans.

E. Veterans with an active high risk for suicide patient record flag (PRF) in the CLC or Domiciliary will be assessed by a qualifying provider during regular clinic business hours and individualized recommendations will be provided to unit staff regarding their care and environment.

III. RESPONSIBILITIES:

A. The Chief of Staff and the facility Director are jointly responsible for initiating, implementing, and assuring compliance with this policy.

B. The Associate Chief of Staff-Primary Care (ACOS-PC), the Associate Chief of Staff-Behavioral Health (ACOS-BH), the facility Director, Community Living Center (CLC) Program Manager and the Mental Health Residential Rehabilitation Treatment Programs (MHRRTP) Chief are responsible for ensuring that Veterans are screened for suicide.

C. Clinicians are responsible for completing suicide risk assessments & screening Veterans for suicide risk, determining level of severity, and developing a suicide prevention safety plan if deemed at high risk.

D. The Suicide Prevention Coordinator (SPC) is responsible for implementation of suicide prevention strategies within the this facility to help ensure that all appropriate measures are being taken to prevent suicide in the Veteran population within the Butler VA catchment area.

E. The SPC, in coordination with treating providers and the Suicide Risk Reduction

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Team, is responsible for determining appropriateness of placing the patient record flag (PRF), reviewing Veterans who have been flagged, and removing the PRF when Veterans are no longer considered at high risk for suicide.

F. Clinical managers are responsible for ensuring that safety procedures for high risk Veterans are followed. Supervisors are responsible for ensuring that all designated employees complete training on an as needed basis and for including it as part of the employee’s competency plan, if applicable.

IV. PROCEDURES:

A. Veterans who present with a primary complaint of an emotional or behavioral problem will be screened for suicide risk. If the screen results are positive, further assessment will be completed and immediate care needs addressed. These assessments will be completed by a qualifying provider who will ensure safety and identify urgent care needs, identify the appropriate setting and specialty for evaluation and treatment, arrange for treatment, respond to the Veteran’s questions or concerns, and facilitate engagement into mental health care.

B. All Veterans who screen positive for depression and/or Posttraumatic Stress Disorder will be screened for suicide by a qualifying provider.

1. Veterans will be asked a standardized set of questions through the clinical reminder system or national template.

2. If the Veteran is seen in Butler’s Primary Care Clinics and the initial screen is positive, a qualifying provider should be contacted to complete a Columbia-Suicide Severity Rating Scale (Columbia). If the Columbia is positive, a Comprehensive Suicide Risk Evaluation (CSRE) will be completed.

3. Veterans who are seen in a CBOC will have the Columbia completed by a qualifying provider. If the Columbia is positive, the Veteran should be connected with a PCMHI provider or other qualifying provider over the phone or through clinical video technology (CVT) immediately so that a CSRE can be completed. Disposition of the Veteran will be based on the recommendation of the qualifying provider.

4. For Veterans who are seen in specialty clinics who are identified as having an emotional or behavioral need, Behavioral Health staff should be contacted and a qualifying provider will complete the Columbia. In the event that a Columbia is positive, a CSRE must be completed by a qualifying provider.

5. During an in-home visit where the screen is positive, the Columbia will be completed by a qualifying provider. If the Columbia is positive and a qualifying provider for completion of the CSRE is not in the home, a qualifying provider must be contacted to complete the CSRE via telephone or VVC. This should be completed with the staff who performed the initial screen present to ensure Veteran safety.

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6. In Home-Based Primary Care, the psychologist or other qualifying provider assigned to the team will complete the CSRE, if applicable. If the psychologist or other qualifying provider is not available, an alternative qualifying provider should be contacted to complete the CSRE by telephone or VVC. Unless the staff’s safety is in jeopardy, the staff member will remain with the Veteran until direction is provided by the qualifying provider. This may include, but is not limited to, waiting for a mobile crisis unit, EMS or local authority to arrive.

7. In community programs other than HBPC, a qualifying provider will complete the Columbia and CSRE, if applicable. In both cases, unless the staff’s safety is in jeopardy, the staff member will remain with the Veteran until direction is provided by the qualifying provider. This may include, but is not limited to waiting for a mobile crisis unit, EMS or local authority to arrive.

8. If a Veteran is determined to be at risk for suicide, a qualifying provider, in conjunction with the SPC will develop a suicide prevention safety plan.

9. If a Veteran presents to Butler VA Health Care System and is determined to be at imminent risk to self or others, arrangements will be made for admission to an inpatient facility. 1:1 observation will be maintained with the Veteran. VA Police will conduct a safety check to ensure that the Veteran does not have any weapons or contraband. The search will be conducted as soon as possible after determination that an inpatient admission is warranted and prior to transfer of the Veteran.

C. Veterans who contact the Butler VA Health Care System or CBOC via telephone or other telecommunication or electronic method during normal business hours with a primary complaint of an emotional or behavioral problem will also be screened for immediate needs and suicide risk through contacting Behavioral Health staff at 724-496- 2315. In the event that this option is not available, Veterans are to be warm transferred to the Veteran Crisis Line at 1-800-273-8255, press option 1.

D. Veterans who are determined to be at high-risk for suicide will be indicated as such, utilizing the Patient Record Flag system.

1. High-risk suicidal Veteran: A Veteran with a current reported or witnessed suicide attempt or current serious identified ideation that requires an immediate treatment plan change such as hospitalization. Presence of any of the following warning signs:

threatening to hurt or kill themselves with a plan; looking for specific ways to kill themselves and seeking access to means such as pills, weapons, or other means; talking or writing about death, dying, or suicide; or a Veteran who is deemed to be at high-risk determined by the judgment of a clinician.

2. Suicide Risk Flag: A flag that appears as a pop-up warning in the patient record system notifying all clinical staff of Veterans who are deemed as high risk for suicide.

E. The Suicide Prevention Coordinator will coordinate suicide prevention strategies and provide education to all facility leadership, managers, and staff and will:

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1. Maintain a record of Veterans at high-risk for suicide, including but not limited to, those who have suicidal ideation and those who survived suicide attempts, as well as others with high-risk behaviors.

2. Attempt contact with all Veterans who have had suicide attempts and advise relevant clinicians of these attempts throughout the facility by including them as additional signers on a templated note.

3. Oversee the tracking of no-show, cancellation and/or rescheduling of appointments by Veterans identified as being at high risk and attempt follow up with them.

4. Ensure that Veterans who are admitted for hospitalization as a result of Self- Directed Violence (SDV) will have a high risk for suicide PRF activated. This initial PRF will be reviewed within 90 days of activation.

5. Ensure that Veterans with a high risk for suicide PRF have 4 visits within the first 30 days after activation of the PRF and 1 visit monthly thereafter until removal of the high-risk PRF.

6. Disseminate, organize, and conduct evidence-based practices for suicide prevention.

7. Promote awareness to all Veterans of how to access assistance if in crisis to include the Veterans Crisis Line at 1-800-273-8255, press option 1, and local 911 access.

8. Work with community resources such as Veteran Service Organizations and other community groups to ensure that they are aware of how to recognize Veterans at risk for suicide and their options for getting these Veterans assistance.

9. Provide ongoing education for providers, Veterans, families, and members of the community on risk factors and warning signs for suicide and treatment options.

10. Attempt follow up with Veterans who call the Veterans Crisis Line.

F. Veterans who are admitted to the CLC or MHRRTP are screened for suicide risk.

In the event a Veteran is admitted who has a PRF or a Veteran becomes suicidal during the admission, the following measures will be taken to continually ensure their safety during the admission:

1. A qualifying provider will be notified for the purpose of initiating further assessment and coordination of care and suicide prevention recommendations.

2. Suicide prevention recommendations may include, but are not limited to:

a. Initiation of 1:1 observation;

b. Transfer of care to another facility;

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c. Consultation with a Behavioral Health medication prescribers for medication recommendations; and/or

d. Completion of a suicide prevention safety plan.

V. REFERENCES:

Eliminating Veteran Suicide: Implementation Update on Suicide Risk, Screening & Evaluation (Risk ID Strategy) Memorandum, Deputy Undersecretary for Health Operations & Management, October 17, 2019.

2019 National Patient Safety Goals – Joint Commission (Behavioral Health Care), effective July 1, 2019: NPSG.15.01.01.

VI. RESCISSION: Medical Center Memorandum PC-15, dated December 16, 2013.

for

SHARON COYLE, MSN, RN, MBA

Interim Director

ATTACHMENT: A

(Automatic Review Date: October 28, 2022)

Butler VA Health Care System Medical Center Memorandum PC-15 Butler, PA October 28, 2019

ATTACHMENT A

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.

Primary

Screen*

Secondary

Screen**

CSRE

MD/DO1 Yes Yes Yes

Licensed Psychologist

(PhD/PsyD)2

Yes Yes Yes

Clinical Pharmacy Specialist Yes Yes Yes

LCSW/LMSW/LISW3 Yes Yes Yes

LMFT4 Yes Yes Yes

LPMHC5 Yes Yes Yes

Addiction Therapist Yes Yes† No

LPN6 Yes No No

RN7 Yes Yes† No

APRN: NP/CNS8 Yes Yes Yes

PA9 Yes Yes Yes

Peer Support Specialist Yes No No

UAP10 Yes No No

RT and MIT11 No No No

PT/OT/KT12 Yes No No

Vocational Rehabilitation

Specialist

Yes No No

Rehabilitation Counselor Yes Yes†† No†††

Psych Tech (psychometrician) Yes Yes† No

*Primary Screen: The Patient Health Questionnaire-9 (PHQ-9) item #9

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

†RN’s, Psych Techs and Addiction Therapists can administer the secondary screen via Mental Health

Assistant or when installed in a note template, but they cannot administer the secondary screen via the

Clinical Reminder System because it contains disposition

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++Rehabilitation Counselors can administer the secondary screen via Mental Health Assistant or, when licensed and included in local bylaws as an independent practitioner, via the Clinical Reminder System +++Yes for Rehabilitation Counselors who hold state licensure and are included in local bylaws as an independent practitioner

1Medical Doctor/Doctor of Osteopathic Medicine; 2Doctor of Philosophy/Doctor of Psychology; 3Licensed

Clinical Social

Worker/Licensed Master of Social Work/Licensed Independent Social Worker; 4Licensed Marriage and

Family Therapist;

5Licensed Professional Mental Health Counselor; 6Licensed Practical Nurse; 7Registered Nurse; 8Advanced

Practice Registered

Nurse: Nurse Practitioner/Clinical Nurse Specialist; 9Physician’s Assistant; 10Unlicensed Assistive

Personnel, including Health Tech, Medical Assistant, and Nursing Assistant; 11Respiratory Therapist and

Medical Instrument Technologists; 12Physical Therapist, Occupational Therapist, Kinesiotherapist

Note: A trainee in ANY of these categories may complete each step marked with a “Yes” with an appropriate co-signer