Michigan 988 Center Protocols.pdf

Michigan 988 Center Protocols

Updated March 2023

Michigan 988 Centers reviewed requirements and standards from Vibrant during a series of workgroup meetings. The following section contains the agreed upon protocols all Michigan 988 Centers will utilize. *Please note that the document contains the Lifeline policy changes on suicide risk assessment and imminent risk*

1. All centers must ask Lifeline-contactors about suicidality using the two prompt questions

(previously three prompt questions):

1. Are you thinking of suicide, including today?

2. Have you taken any action to harm yourself today?

An affirmative answer will require that the worker conduct a full suicide risk assessment, consisting of the following core principles: Suicidal desire, Suicidal intent, Suicidal capability, and Buffer/connectedness. See Appendix A for recommended formatting of

Suicide Risk Assessment.

2. All centers must ask contactors about homicidal ideation. Questions on homicidal ideation can include, but are not limited to:

1. Have you ever thought of harming someone, including today?

2. Have you taken any action to be violent toward or harm anyone, including today?

An affirmative answer will require that the worker conduct a risk assessment. Workers can use the Suicide Risk Assessment in Appendix A as a guide. If it is determined that the contactor is dangerous to others, the workers should contact 911 and conduct a relay of information.

3. Workers must use active engagement with at risk contactors, using empathy and positive regard, to create a safety plan. This information should be recorded in a safety assessment. Workers should use the least invasive intervention, while collaborating with the contactor on their wishes and willingness in the creation of a safety plan. See

Appendix B for examples of how to establish rapport to promote the contactor’s collaboration in securing their safety and Appendix C for examples of recommended intervention measures for contactors at imminent risk.

4. Any involuntary emergency interventions (previously referred to as Active Rescue) should always be the last resort and only initiated in circumstances where the individual at risk is unable to participate in a plan to keep themselves safe. It is understood that this is a

“judgement call” that is based on the contactors means, willingness, assessment, safety plan, etc. Workers should take advantage of all available resources to aide in the determination of if the contactor requires an involuntary emergency intervention (e.g., 911) and consult with an appropriately trained and credentialed clinician when it is determined that an involuntary emergency intervention is necessary. Please see Appendix D for the involuntary emergency intervention workflow.

5. When involuntary emergency intervention is determined to be necessary, and 911 needs to be contacted, the 988 worker will contact 911 and conduct a relay of information.

6. If a contactor agrees to a voluntary emergency intervention, it is recommended that the

988 worker contacts 911 or stays on the line to confirm contact was made. The 988 worker will follow up within 24 – 72 hours. The 988 worker can encourage the contactor to call

988 back for support.

a. If the contactor chooses to call 911 themselves, the 988 worker will document it in their report and should offer follow up services.

7. Centers should confirm at risk contactors did receive the emergency help they needed when an involuntary emergency intervention occurs. This can be done by contacting the

Public Safety Answering Points (PSAPs) to confirm contact was made with the at-risk contactors. Centers should contact the PSAP within a few hours of the phone call, but no sooner than one hour.

1. Workers should request an incident number and must provide verification when making inquiries to ensure that information is being passed along to the correct person (ex: provide a PIN to PSAP). The 988 worker should also inform the PSAP which 988 center they are from and provide their center’s backdoor number.

2. Information that can be received during follow-ups include:

i. Confirmation contact with the individual at risk was made

1. The worker may also stay on the line with the caller until the emergency service providers has arrived and their presence is apparent.

ii. Transport status

iii. Name of responsible agency

iv. Name of receiving facility, if available

8. Supervisors will complete a review of emergency interventions in a timely manner.

Supervisors will review the emergency intervention with the call taker from the encounter on an as needed basis.

9. In circumstances where a Third-party contactor is reporting that another individual is at imminent risk of suicide, it is recommended that workers actively engage the contactor to gather all relevant information from the contactor related to the other’s reported risk status, to the degree the contactor can provide such information (see Lifeline Suicide Risk

Assessment Standards for ascertaining risk);

o Obtain contact information from the Third-party contactor, as well as information about his/her relationship to the person at risk, towards better ensuring informant reliability and the contactor’s collaboration in planning interventions to reduce risk;

and o Obtain contact information for the person at risk from the Third-party contactor, to the degree known.

When working with a Third-party contactor and planning interventions/actions, workers should seek the least invasive, most collaborative approach towards ensuring the safety of the individual at risk. Please see Appendix E for examples of recommended measure that may be undertaken by staff when working with Third-party contactors.

10. Centers should have collaborative relations with local Mobile Crisis Teams, emergency departments, police departments, referral services (e.g., 2-1-1), if applicable.

11. Michigan centers agree to align the Michigan 988 Center Protocols for follow up for crisis contactors whose safety assessment determined they were at moderate or high risk with the Recommendations & Best Practices involving follow up recommended by Lifeline.

a) Centers will initially provide follow up for all crisis contactors when suicide risk assessment indicates a moderate or high level of risk. If/when centers have the capacity, they will provide follow up for all crisis contactors.

b) All contactors that confirm current suicidal ideation (at the time of the call or within the past 24 hours) during their interaction with the Lifeline will be asked for consent to follow-up services.

c) Contactors must consent to follow-up services if they want to participate.

d) The 988 call taker must have gone through crisis counselor training from the center as well as training in follow-up requirements in order to conduct clinically appropriate call.

e) First contact should typically occur within 24 - 72 hours after the original contact with the Lifeline. Contacts needed sooner than 24 hours are often done as part of a safety check outreach call and are particularly helpful for those who need additional support and do not want/need to go to an ER. People who receive safety check calls can also be asked for consent to participate in a follow-up program once the period of immediate safety is no longer a concern.

f) Individuals who have consented to follow-up should receive a minimum of 2 follow-up contacts.

At least three attempts should be made to make contact with the individual if the individual is not reached for a scheduled follow up. At least one of the three attempts should be tried on a different day in case the follow-up participant is away that day unexpectedly. Workers need to ask permission to leave voicemails, along with what time range would work best for the follow-up call.

g) At a minimum in each follow-up contact: Assess the individual’s current well-being and suicide risk, review and update safety plan as needed, coordinate care with other providers, and increase connection to needed services.

h) Centers should ensure that the follow-up program is included in all staff and volunteer trainings to promote full integration of the service and enhance sustainability of the program.

i) Centers will track and report metrics regarding follow up services.

a. Number of contacts/encounters enrolled in follow up: The total number of contacts/encounters who consented to be followed up with (per month)

b. Number of contacts/encounters successfully contacted: The total number of contacts/encounters who consented to be followed up with who were also reached by the 9-8-8 call taker (per month)

c. Number of contacts/encounters who received wellbeing follow up: The total number of contacts/encounters who were successfully contacted to follow up regarding their well-being. For example, following up with contacts who were determined to be at high risk of suicide.

d. Number of contacts/encounters who received ongoing services follow up: The total number of contacts/encounters who were successfully contacted to follow up regarding their ongoing services. For example, verifying the receipt of referrals.

e. Average number of attempts made per encounter: The average number of attempted contacts made to successfully reach the contact/encounter (per month). Note that call takers should attempt 3 contacts.

f. Total number of contacts for the followed up contact/encounter: The total number of successful contacts made for the contact/encounter (per month). Note that a caller may wish to receive more than one follow-up call.

j) Ensure that you have a consistent approach and plan for familiar contactors.

Remember to reiterate the purpose of the follow-up program, which is to provide short-term, limited check-in calls based on a prepared safety plan. Workers should use language like “What has changed since the last time you contacted us?”, or “Have you worked on the things we talked about last time”. Use collaborative conversation.

Familiar contactors may need to be reminded of the limits you set with them.

Appendix A – National Suicide Prevention Lifeline (NSPL) Suicide Risk Assessment Standards

PROMPT QUESTIONS

CORE PRINCIPLES & SUBCOMPONENTS

SUICIDAL DESIRE SUIDICAL CAPABILITY SUICIDAL INTENT BUFFER/CONNECTEDNESS

Suicidal Ideation

• Killing self and/or others

History of suicide attempts Attempts in progress Immediate supports

Psychological pain Exposure to someone else’s death by suicide

Social supports

History of/current violence to others

Plans to kill self/other

• Method known

Planning for future

Hopelessness Available means of killing self/other

Engagement with helper

• Telephone worker Helplessness Currently intoxicated

Perceived burden on others Substance abuse Preparatory behavioral Ambivalence for living/dying

Feeling trapped Acute symptoms of mental illness, for example:

• Recent dramatic mood change

• Out of touch with reality

Core values/beliefs

Feeling intolerable alone Extreme agitation/rage, for example:

• Increased anxiety

• Decreased sleep

Expressed intent to die Sense of purpose

Are you thinking of suicide, including today? Have you taken any actions to harm yourself today?

Appendix B – Suicide Risk Assessment Guiding Questions

Desire

Hopelessness reflect feeling hopeless

What would have to happen for you to feel like things might get better?

Helplessness reflect feeling helpless

What can you do to help yourself?

What have you tried in the past?

Perception of Being a Burden

How would it be for (family, friends, etc.) if you killed yourself?

Feeling Trapped reflect feeling trapped

Suicide is one option. What other options could you try?

Recent Losses Does call mention recent losses (relationship, job, house, etc.)?

Psychological Pain I can hear you’re struggling to cope with the pain you’re feeling.

Feeling Alone reflect feeling alone

It sounds like you know that there are people who care about you, but that you still feel alone.

Capability

Availability of Means Do you have the .… with you?

Prior Attempts Have you ever tried to kill yourself?

Lost Someone to Suicide

Have you ever lost someone to suicide?

Highly Agitated Does caller seem to be agitated?

• It sounds like you’re feeling agitated.

History of Violence to Others

• Could you tell me if you’ve ever been violent toward anyone else?

• Have you every harmed, or had thoughts of harming, anyone else?

Recent Violent Act/Threats

(You’ve said that you’ve thought of killing yourself.) Have you ever had thoughts of harming anyone else? (If yes, do Homicide Assess.)

Frequently Abuses Subs.

Can you tell me how often you drink or use other substances?

Using Substances Today

Have you been drinking or using any drugs today?

Recent, Dramatic Mood Change

• Is the mood you’re in different from the way you usually feel?

• You’ve said that you’ve been feeling (anxious, depressed, etc.) How long have you been feeling that way?

Insomnia Have you been sleeping?

Increased or Severe Anxiety

• Have you been feeling more anxiety than usual?

• Have your thoughts been racing more than usual?

Out of Touch with Reality

• Have you heard voices that tell you to hurt or to kill yourself?

• Do you have a mental illness diagnosis?

• Does caller seem out of touch with reality?

Fear of Attempting Does it frighten you to think about carrying out your suicide plan?

Intent Suicide Plan • Could you tell me how you would kill yourself?

• Have you thought about how you would kill yourself?

Steps taken in Preparation

• Have you taken any steps toward suicide?

• Have you done anything to prepare?

Attempts in Progress • Have you already started to (whatever the plan is)?

• Have you done anything to try to kill yourself today?

Expresses Intent to Die • How likely are you to kill yourself today (on a scale of 1-5)?

• Do you feel like you’ll be okay/safe?

Buffers Good Connection with Caller

• Is caller agreeable to NSP or a follow-up, or do you feel like you were able to develop a good relationship with the caller?

• NSP: Would you promise me that you will call and talk to the Crisis Center (or got to the hospital) before you do anything to hurt or kill yourself?

Others Aware and Nearby

• Is anyone with you right now

• Does that person know how you’re feeling?

Helpful Social Supports Do you have anyone you’re able to turn to? (family, friend, counselor)

Ambivalence about Suicide reflect feeling torn or ambivalent

• It sounds like there’s a part of you that wants to live, and a part that wants to die.

• I can hear that, on one hand you want to die because ________, but on the other hand you want to live because

Committed to Future Plans

• Before you started feeling this way, did you have plans for the future?

• Is there anything you’ve been hoping to accomplish?

• You’ve said that you have plans to (keep an appointment, or some other example of future plans you’ve heard in the call).

Are you willing to keep that commitment?

Values / Beliefs Support Living

• If someone you cared about was thinking about suicide, what would you say to them?

• What would it take for you to stay alive?

Feels a sense of Purpose

What has kept you alive so far?

Concerned Over Consequences

• How do you think it will be for your family/friends if you kill yourself?

• Who will find you? How will that be for them?

Appendix C – Examples of Recommended Intervention Measures for

Contactors at Imminent Risk *The following examples are alignment with Appendix 4 of Lifeline’s Policy for Helping Callers at

Imminent Risk of Suicide*

Examples of recommended approaches for staff in helping contactors at Imminent Risk include, but are not limited to:

• Obtaining agreement from the contactor to take actions on his/her own behalf that immediately reduce Imminent Risk (i.e., intent to die in the immediate sense is diminished and replaced by actions and plans intended to enhance the contactor’s personal care and safety);

• Obtaining agreement from a significant other as well as from the contactor that said significant other will intervene towards better assuring the safety of the contactor;

• Obtaining agreement from the contactor to participate in a three-way call with a professional currently treating the contactor, thus returning responsibility to the primary professional overseeing the contactor’s ongoing care. Such interventions are most effective in ensuring ongoing safety when workers completely explain to the treatment professional why the contractor has been assessed to be at Imminent Risk;

• Obtaining agreement from the contactor to receive an evaluation in his/her home by a mobile crisis/Crisis Stabilization Units (CSUs)/outreach team trained and licensed to conduct such behavioral health examinations;

• Securing transportation for the person at risk to a hospital emergency room to undergo life-saving medical procedures, treatments and/or psychiatric evaluation; and

• Contacting public safety officials (e.g., police, sheriff) to facilitate a home visit to assess the safety of the contactor, when no other less invasive method is available to determine the contactor’s safety.

Note: The above list of examples is not all-inclusive and should not to be viewed as examples of

“acceptable course of actions” outside the actual context of any specific call. These examples should be understood as common measures often undertaken on hotline calls that are in the general spirit of concordance with National Suicide Prevention Lifeline Guidelines, with the understanding that appropriate interventions can only be determined by the specific safety needs of an individual contact or contactor.

Appendix D – Involuntary Emergency Intervention Workflow

Appendix E – Recommended Procedures for Third-Party Reporting

Imminent Risk *The following examples are alignment with Appendix 5 of Lifeline’s Policy for Helping Callers at

Imminent Risk of Suicide*

Examples of recommended measures that may be undertaken by workers when working with Third-party contactors include, but are not limited to:

• Facilitating a three-way call with the Third-party contactor and the person reported to be at risk so that workers may assess and intervene with the individual directly, with the support of the Third-party contactor’s concerns and information;

• Facilitating a three-way call with the Third-party contactor and the treatment professional to discuss the current situation and potential safety plans, only if the person at risk is in treatment, unwilling or unable to inform his/her caregiver of his risk, and the Third-party contactor has access to the caregiver’s contact information and agrees to a three-way call;

• Confirming that the Third-party contactor is willing and able to take reasonable actions to reduce risk to the person, such as:

o Removing access to lethal means, o Maintaining close watch on the person at risk during a manageable time interval between the Call and the scheduled time when the person is seen by a treatment professional, or o Escorting the person at risk to a treatment professional or to a local urgent care facility (e.g., hospital emergency room)

• Obtaining agreement from the Third-party contact to collaborate with a mobile crisis/Crisis Stabilization Units (CSUs)/outreach service facilitated by workers to evaluate the person at risk within a time frame that—in the best judgment of workers—is reasonable in that it accounts for current level of risk;

• Using information obtained from the Third-party contactor to contact another third party or the individual at risk directly, in cases where the Third-party contactor is either unwilling or unable to help directly with the intervention.