S02 - Attachment 10 - Numbered Memorandum 116-09-13 Suicide Risk Management Program.docx

Attachment 10

SUICIDE RISK MANAGEMENT PROGRAM

1. PURPOSE: To outline the facility’s comprehensive program for safeguarding Veterans at risk for suicide.

2. POLICY: It is the policy of the Spokane Veteran Affairs (VA) Medical Center to actively prevent and mitigate suicide risk among Veterans entrusted to our care. This is accomplished as we foster a culture of suicide risk awareness and prevention, provide all staff with training appropriate to their positions, proactively assess suicide risk among our Veteran patients, and actively intervene to assist Veterans with identified risk.

3. DEFINITIONS:

a. Safety Plan: A specific plan developed by a Veteran, typically with the assistance of a provider, for reducing suicidal risk and assuring their personal safety. The development of a safety plan is a critical element of helping Veterans at high risk for suicide. The elements of safety planning process are described in paragraph 4e(3)(b), below.

b. Suicide: Suicide is taking of one’s own life with conscious intent.

c. Suicide Attempt: A suicide attempt is any action taken by an individual with conscious intent believed to cause death, but not resulting in death.

d. Suicidal Behavior: Suicidal behavior is that in which anyone threatens self-harm or otherwise exhibits behavior known to be associated with self-harm (e.g. suicidal gesture). Threats of harm should be taken as serious statements of intent unless there is compelling contrary evidence and/or professional consultation indicating otherwise.

e. Suicide Risk Assessment: A structured or unstructured assessment of risk factors, protective factors, and warning signs for suicide identified from the clinical literature. For the purpose of this policy structured risk assessments include these:

(1) Preliminary Risk Assessment (PRA): A relatively brief assessment of a Veteran’s current potential for self-harm. The PRA consists, at minimum, of the screening questions outlined in Attachment A: Preliminary Risk Assessment Questions. (These questions currently constitute VHA’s national clinical reminder for suicide risk screening following a positive screen for depression or post-traumatic stress disorder.)

(2) Detailed Risk Assessment (DRA): A thorough evaluation of a Veteran’s current potential for self-harm, conducted in a face-to-face evaluation of the Veteran by a Licensed Independent Practitioner (LIP), which requires the provider to assess specific evidence-based risk and protective factors. The DRA leads to an overall assessment of current risk for suicide, as well as a recommended plan of care. The DRA consists, at minimum, of the questions outlined in Attachment B: Detailed Suicide Risk Assessment. (These questions currently constitute Veterans Integrated Service Network (VISN) 20 standardized Detailed Suicide Risk Assessment.)

f. Suicide Risk Levels:

(1) Imminent Risk of Suicide: A Veteran is considered at Imminent Risk of Suicide when an evaluating clinician judges, based on the presence of risk factors and warning signs and a lack of protective factors, that there is a high likelihood that the Veteran will attempt suicide unless immediate action is taken. Imminent risk typically results in psychiatric hospitalization.

(2) High Risk of Suicide: A Veteran is considered at High Risk of Suicide when an evaluating clinician judges, based on the presence of risk factors and warning signs and a lack of protective factors, that there is a high likelihood that the Veteran may attempt suicide in the near future should risk factors increase. The distinction between Imminent and High Risk typically depends on whether a Veteran has stated the intent to end their life, has a specific suicide plan, has access to lethal means of suicide, and/or is willing to actively engage in safety planning. A Veteran deemed at High Risk may not require psychiatric hospitalization to remain safe but does require timely intervention and an enhanced level of care; treatment must include focused efforts to reduce risk and assure safety.

(3) Moderate Risk of Suicide: A Veteran is considered at Moderate Risk of Suicide when an evaluating clinician judges, based on the balance of risk factors, warning signs, and protective factors, that there is some likelihood that the Veteran may attempt suicide in the future should risk factors increase. Veterans at moderate risk require ongoing monitoring of risk factors, warning signs, and protective factors.

(4) Low Risk of Suicide: A Veteran is considered at Low Risk of Suicide when an evaluating clinician judges, based on an absence of warning signs and the balance of risk and protective factors, that there is low likelihood that the Veteran would attempt suicide. Specific intervention to address risk factors is not indicated for Veterans at low risk. Periodic reassessment of suicide risk is appropriate for all Veterans.

4. PROCEDURES:

c. Training in suicide risk identification and management.

(1) New staff members receive an orientation to suicide risk management as part of their new-employee orientation (NEO). This training includes an introduction to suicide risk factors and warning signs, as well as orientation to front-line responses to identified suicide risk.

(2) After NEO, clinical staff receive training in suicide risk management appropriate to their duties and clinical privileges. All clinical staff are assigned to complete the Suicide Risk Assessment for Clinicians course in TMS within 90 days of starting work. Clinical staff who screen patients are trained to conduct Preliminary Suicide Risk Assessments. Licensed Independent Practitioners (LIP) who work in Behavioral Health, Primary Care, Emergency Department, and other clinical settings receive training to conduct a Detailed Risk Assessment.

(3) Non-clinical staff—especially those who interact with patients--are invited to complete suicide risk QPR Gatekeeper training within 90 days of starting work.

(4) Staff members receive periodic training updates in suicide risk management, offered through the facility Suicide Risk Management Team and/or TMS training modules. The facility Suicide Prevention Coordinator (SPC) keeps staff aware of other available training, such as the Suicide Risk Assessment with Older Veterans course in in TMS.

(5) For all staff, training in suicide risk management includes attention to risk factors, warning signs, and protective factors highlighted in the current research. For addition information, see the VHA’s Suicide Risk Assessment Guide, VHA Suicide Risk Pocket Card, and Risk Factors for Suicide in OEF/OIF Veterans, all available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp.

d. Proactively assessing suicide risk among Veteran patients.

(1) The assessment of suicide risk is considered a fundamental element of clinical care and may occur in any hospital setting.

(2) Non-clinical staff and those who are not authorized to complete clinical reminders are do not formally assess suicide risk; however, all staff are trained in front-line suicide awareness and basic intervention strategies. Within this context, all staff members are encouraged to take appropriate steps to assist Veterans or others they feel may be at risk.

(3) Formal suicide risk assessment consists of the Preliminary Risk Assessment and the Detailed Risk Assessment.

(a) Preliminary Risk Assessment.

1. The Preliminary Risk Assessment (PRA) is a relatively brief assessment of a Veteran’s current potential for self-harm. The PRA consists, at minimum, of the screening questions outlined in Attachment A: Preliminary Risk Assessment Questions. (These questions currently constitute VHA’s national clinical reminder for suicide risk screening following a positive screen for depression or post-traumatic stress disorder.)

2. A PRA is conducted whenever a treating clinician has concerns that a Veteran may be at risk for suicide. Providers must remain aware of life changes that may increase risk for suicide, even in the absence of a mental health diagnosis or reported depression. These can include escalations in relationship problems, financial problems, serious medical illness, chronic pain, and other risk factors. A PRA may be conducted at any point during the course of a Veteran’s clinical care.

3. A Preliminary Risk Assessment is required in the following situations:

a. Whenever current or recent suicidal ideation, intent, planning, or behavior is part of a Veteran’s presenting complaint;

b. Whenever a Veteran reports a new complaint of emotional or behavioral distress, including when a mental health diagnosis is made for the first time;

c. Whenever a Veteran with a previously assessed mental health disorder manifests a significant escalation in subjective distress, life stressors, or behavioral risk factors such as substance abuse.

d. Whenever a Veteran report to the Emergency Department for urgent mental health services

e. As part of every mental health intake evaluation;

f. As part of admission to the inpatient psychiatric unit. (In this case, the PRA is always followed by a DRA, as noted below.)

g. As part of admission to an inpatient medical (non-psychiatric) unit, when mental health symptoms or diagnoses have been identified and are judged likely to impact the course of care;

h. Within 48 hours prior to discharging a Veteran from the inpatient psychiatric unit;

i. Within 48 hours prior to discharge from an inpatient medical (non-psychiatric) unit, when active mental health symptoms or diagnoses have been identified during the course of care;

j. Whenever a Veteran has obtained a positive screen for depression or post-traumatic stress disorder (including screenings completed as clinical reminders).

4. A PRA may be administered by any Licensed Independent Practitioner (LIP) or by another clinical staff member working under the supervision of an LIP who has been trained in its use. When the PRA is administered by a non-LIP, the results are reviewed with an LIP.

(b) Detailed Risk Assessment.

1. A Detailed Risk Assessment (DRA) is a thorough evaluation of a Veteran’s current potential for self-harm, conducted in a face-to-face evaluation of the Veteran by a Licensed Independent Practitioner (LIP), which requires the provider to assess specific evidence-based risk and protective factors. The DRA leads to an overall assessment of current risk for suicide, as well as a recommended plan of care. The DRA consists, at minimum, of the questions outlined in Attachment B: Detailed Suicide Risk Assessment. (These questions currently constitute VISN 20 standardized Detailed Suicide Risk Assessment.)

2. A Detailed Risk Assessment (DRA) is typically conducted following a positive PRA; however, a DRA may be conducted whenever an evaluating provider judges that a thorough review of suicide risk and protective factors is warranted.

3. A DRA is required in the following situations:

a. Whenever a positive PRA is obtained. Specifically, a DRA is required whenever a clinician who completes a PRA for a Veteran determines that the Veteran does exhibit signs of elevated risk for suicide.

b. Whenever a Veteran endorses suicidal ideation in combination with suicidal planning, suicidal intent, a history of suicidal gestures, or a history of suicide attempts;

c. As part of admission to the inpatient psychiatric unit, with the following qualifications:

1. If a DRA was completed as part of the psychiatric triage evaluation that led to admission, the DRA does not need to be redone as part of the admission process. In this case, the triage DRA may be referenced in the admission records.

2. If a Veteran receiving psychiatric triage is determined to need hospitalization before a DRA can be initiated or completed, the DRA may be discontinued and the decision to hospitalize the Veteran documented instead. If the Veteran is hospitalized at the VA Medical Center, the DRA is completed as part of the admission history.

d. When a Veteran is discharged from the inpatient psychiatric unit, a PRA must be conducted within 48 hours prior to discharge. Historical elements and unchanging risk factors assessed documented in the admission DRA do not need to be reassessed for the discharge PRA.

4. Whereas a PRA may be conducted by any provider deemed qualified by the facility to complete clinical reminders in Computerized Patient Records System (CPRS) including nursing staff, the DRA may only be conducted by the following providers:

a. Licensed mental health providers in the following disciplines may conduct DRAs: psychiatrists, nurse practitioners, physician assistants, psychologists, social workers, and mental health counselors. Licensed providers in these disciplines may conduct DRAs regardless of whether they work in a specialty mental health or primary care setting. Unlicensed trainees in these disciplines may complete DRAs but must obtain appropriate supervision and co-signatures.

b. In addition to mental health providers, DRAs may also be completed by physicians, mid-level medical providers, and licensed social workers, as well as supervised trainees in these specialties.

(4) Unstructured risk assessment. When working with a Veteran for whom suicide risk has previously been ruled out through formal assessment, it is acceptable for a clinician to periodically review any changes in risk factors, protective factors, and/or warning signs without conducting a structured, formal suicide risk assessment. Should such a review lead the provider to suspect an increase in risk, a formal risk assessment shall be conducted.

(5) Documentation of risk assessment. The results of suicide risk assessments are promptly documented in the Veteran’s electronic medical record. Structured assessments of suicide risk (i.e. PRAs and DRAs) are documented using standardized CPRS templates. Unstructured reviews of suicide risk may be documented independently or as part of a mental status exam or review of systems.

e. Actively intervening to assist Veterans with identified suicide risk.

(1) When a clinician determines that a Veteran is at elevated risk of suicide, action is immediately taken to assure safety of the Veteran. The appropriate action depends on the setting, the level of risk identified, the Veteran’s other treatment needs, as follows

(2) When imminent risk of suicide is identified, the following principles apply. More specific guidance can be found in Numbered Memorandum 116-01-13.

(a) Veterans at imminent risk of suicide are not left alone.

(b) In an inpatient setting, a one-to-one observation is immediately initiated (see Numbered Memorandum 116-01-13), and consultation requested from the psychiatric triage team.

(c) In an outpatient setting, emergency care is immediately be sought through the Emergency Department (ED). Ideally, the Veteran is escorted to the ED by the treating clinician and a warm-handoff provided to ED staff.

(d) Efforts are made to engage the Veteran in the process of seeking safety.

(e) Care is taken to secure the safety of each Veteran in the least restrictive manner possible. To assure safety, any Veteran checked in to the ED and identified as being at high risk for suicide is placed on one-to-one observation.

(f) When necessary to ensure the Veteran’s safety, restraint may become necessary, and VA Police assistance may be required (see Numbered Memorandum 11-17-13: The Use of Seclusion and Restraints). Should a patient at imminent risk of suicide leave VA grounds, city police are immediately notified.

(g) When necessary to ensure the Veteran’s safety, psychiatric admission will be initiated through the ED, in collaboration with the psychiatric triage team.

(3) When a Veteran is found to be at high or moderate risk but not at imminent risk for suicide, the following principles apply:

(a) When suicide risk is present, the immediate focus of clinical care becomes assuring the Veteran’s safety.

(b) The care plan includes helping the Veteran develop a Safety Plan. Clinicians may make use of the VHA Safety Plan Treatment Manual to Reduce Suicide Risk (2008), the VHA Safety Plan Quick Guide for Clinicians, both available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp, or other resources when engaging Veterans in safety planning. Whether or not these resources are used, safety plans includes the following elements:

1. Helping the Veteran identify warning signs that may precede a suicidal crisis;

2. Helping the Veteran develop personal or social strategies for warding off a potential suicidal crisis;

3. Helping the Veteran make plans to engage the support of friends or family;

4. Helping the Veteran connect with mental health resources;

5. Helping the Veteran limit their access to potentially lethal means of suicide, such as by temporarily removing weapons from the home.

(c) The care plan includes connecting the Veteran with the appropriate mental health resources. This occurs in the following ways:

1. For Veterans who are hospital inpatients, a consult is submitted to the psychiatric consultation service.

2. For outpatients who are already receiving mental health care, the treating provider notifies the mental health clinician or team of the newly identified risk. At minimum, this is done by co-signing the provider on the CPRS note documenting the risk. When possible, the mental health team is also made aware of the identified risk through a phone or e-mail message.

3. For outpatients who are not already receiving mental health care, a CPRS consult is submitted to the Mental Health Clinic. Veterans for whom consults are submitted typically receive a mental health intake evaluation within 14 days.

4. Whenever suicide risk is identified, the facility Suicide Prevention Coordinator (SPC) is also cosigned on the CPRS note documenting the identified risk. The treating provider may also call or e-mail the SPC regarding the case. When notified, the SPC responds by reviewing the record to highlight risk and protective factors, by making clinical recommendations to the treating provider, and by considering placing the Veteran’s on the facility’s High Risk List in accordance with VHA Directive 2008-036: Use of Patient Record Flags to Identify Patients at High Risk for Suicide.

(d) Elevated suicide risk is often tied to a specific crisis in the life of a Veteran. Those who care for Veterans at risk of suicide should thus consider temporarily increasing the frequency of contact in order to provide additional support to the Veteran until contributing life crises subside.

(e) The care plan involves Veterans’ family members, to the degree that the Veteran permits and to the degree that the treating provider judges clinically beneficial.

(f) The care plan includes providing the high-risk Veteran with contact information for the Veteran’s Crisis Line (1-800-273-8255 / Press 1). Veterans with potential suicide risk are also encouraged to report to the nearest Emergency Department should a suicidal crisis arise.

(g) The care plan involves the periodic reassessment of risk factors, based on the nature of risk factors and the level of identified level of risk. Careful attention is paid to changes in life stressors and other non-static risk factors. Whether or not a structured risk assessment is used (e.g. the PRA or the DRA), reassessment of risk is documented in the patient’s medical record.

f. Additional suicide risk management activities.

(1) Suicide Risk Management (SRM) Team. The facility’s SRM Team provides consultation, training, case monitoring, transition support, and other services in support of clinicians treating patients at elevated risk for suicide. Whenever a Veteran is found to be at high risk for suicide, the Suicide Prevention Coordinator (SPC) shall be notified through co-signature on the CPRS note, by secure e-mail, and/or by telephone (509-434-7288). Any staff member may consult with the SRM Team about a Veteran by e-mail or by calling 509-434-7288.

(2) Facility High Risk List (HRL). The facility SPC maintains a list of Veterans who have been identified as being at high risk, in keeping VHA Directive 2008-036: Use of Patient Record Flags to Identify Patients at High Risk for Suicide. The purpose of the list is to assist clinicians in providing an enhanced level of care (e.g. increased frequency of visits, monitoring of risk factors by SRM team, automatic notification of the SPC for missed appointments) for Veterans known to be at high risk of suicide and receptive to this level of care. Any clinician may refer a Veteran to the facility SPC for consideration for placement on the HRL. Veterans are made aware of their placement on the HRL and may choose to decline.

(3) Placement on the HRL includes the placement of a Suicide Risk Flag on the Veteran’s CPRS record. This flag alerts all those involved in the Veteran’s care to the elevated risk, with the intent that the treatment team will consider application of the assessment/intervention principles in this numbered memorandum as part of their care for the Veteran. Veterans are removed from the HRL when their risk for suicide is no longer elevated, or at their request.

(4) For Veterans on the facility HRL, missed appointments receive an extra measure of attention. The facility SPC is automatically made aware of each such cancellation or no-show, and follow-up options are considered with the treatment team. The possibility of a law-enforcement welfare check to verify the safety of the Veteran is considered. At least 3 good-faith efforts are made to reschedule the missed appointment.

(5) The Veteran’s Crisis Line (1-800-273-8255 / Press 1) is a national 24-hour service that provides telephone crisis intervention to Veterans who call as well as connecting Veterans with local resources. The facility Suicide Prevention Coordinator serves as the facility point of contact for the Crisis Line and responds to messages from the Crisis Line by contacting the Veteran to provide support within one business day. Responses to Crisis Line calls are documented in CPRS.

4. RESPONSIBLITIES:

a. The Medical Center Director is responsible to:

(1) Promote a culture of proactive suicide risk awareness and psychological safety.

(2) Provide resources needed to support SRM Program execution.

(3) Support orientation and ongoing training of all hospital staff to support SRM activities.

(4) Hold subordinate leaders accountable for implementation of elements of the facility SRM Program.

b. The Chief of Staff is responsible to:

(1) Ensure training of all clinical staff in SRM policies and practices.

(2) Support culture of suicide risk awareness and management, overseeing performance of clinicians of all disciplines with regard to their suicide risk management practices.

(3) Support culture of psychological safety and systemic improvement, particularly when suicides occur

c. The Associate Director for Patient Care Services is responsible to:

(1) Ensure training of all nursing staff in SRM policies and practices.

(2) Support culture of suicide risk awareness and management, overseeing performance of nurses of all practice levels with regard to their suicide risk management practices.

(3) Support culture of psychological safety and systemic improvement, particularly when suicides occur.

d. The Associate Director is responsible to:

(1) Ensure training of all non-clinical staff in SRM policies and practices.

(2) Support culture of suicide risk awareness and psychological safety.

f. The Chief, Behavioral Health Service is responsible to:

(1) Oversee implementation and operation of all aspects of SRM Program.

(2) Ensure communication of SRM policies and practices throughout facility.

(3) Serve as subject matter expert for mental health care delivery, including SRM best practices.

(4) Set positive tone of suicide risk awareness and management within service.

(5) Directly supervise facility Suicide Prevention Coordinator.

(6) Provide briefs, reports, and program reviews to facility leadership.

(7) Ensure SRM Team has resources needed to function effectively.

e. Service Chiefs are responsible to:

(1) Ensure training and readiness of all staff in SRM policies and practices.

(2) Ensure execution of SRM policies and practices within respective services.

f. The Suicide Prevention Coordinator is responsible to:

(1) Implement all aspects of SRM Program throughout facility.

(2) Foster a culture of suicide risk and awareness throughout facility.

(3) Develop, provide, and make available SRM training for clinical and non-clinical staff at all levels.

(4) Develop and provide quality outreach regarding SRM efforts on behalf of Veterans, and make this available to community partners, Veterans, and family members.

(5) Develop tailored outreach and training for internal and external customers focusing on the needs of special populations of Veterans (e.g. Homeless, OEF/OIF, VSO’s).

(6) Participate in regional and national committees charged with improving SRM practices for Veterans.

(7) Contribute to local policy development and revision.

(8) Assist facility and regional providers of all disciplines in providing best-practice assessment and treatment for Veterans at risk for suicide.

(9) Oversee SRM Case Manager(s) in execution of all elements of SRM Program, including consultation with providers, review of cases for HRL placement, monitoring and care for Veterans on HRL, initiating of welfare checks, responding to missed appointments of high-risk Veterans, etc.

(10) Respond in timely and appropriate way to Veteran Crisis Line calls.

(11) Gather, maintain, analyze, and present data on suicide behavior, attempts and completions.

(12) Convene or take lead role in Root Cause Analyses (RCA) and Behavioral Autopsies involving suicide completions.

(13) Research, complete, and submit suicide behavior reports, issue briefs, data aggregates, and other reports as assigned.

(14) Advise leadership on SRM Program strategies, challenges, and initiatives.

(15) Liaise and collaborate with community partners (e.g. non-Veteran crisis lines, community mental health agencies) to assure quality of SRM support for Veterans.

g. Clinical Staff are responsible to:

(1) Maintain awareness and current training in SRM principles, policies, and processes. This includes current awareness of risk and protective factors, warning signs, and elements of safety planning, and clinical tools

(2) Provide suicide risk assessments, in keeping with training, experience, and applicable policy.

(3) Provide care to Veterans at risk for suicide, in accordance with provisions of this policy.

(4) Coordinate with SPC as directed by policy to ensure safety of Veterans in their care.

h. Non-clinical Staff are responsible to:

(1) Maintain awareness and current training in SRM principles, policies, and processes. This includes current awareness of risk and protective factors, warning signs, and front-line intervention strategies.

(2) Take an active role in SRM, as situation requires.

5. REFERENCE(S): VHA’s Suicide Risk Assessment Guide.

(available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp) VHA Suicide Risk Pocket Card (available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp) VHA Safety Plan Treatment Manual to Reduce Suicide Risk (available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp) VHA Safety Plan Quick Guide for Clinicians (available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp) Risk Factors for Suicide in OEF/OIF Veterans (2009) (available at http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp) Warning Signs for Suicide in Veterans (available at http://www.mentalhealth.va.gov/suicide_prevention/ VHA Directive 2008-036: Use of Patient Record Flags to Identify Patients at High Risk for Suicide Numbered Memorandum 11-17-13: The Use of Seclusion and Restraints Numbered Memorandum 116-01-13 (draft), Responding to Veterans at Imminent Risk for Suicide Numbered Memorandum 116-03-13 (draft), Admission to Inpatient Psychiatry

6. RESCISSION(S): Numbered Memorandum 116-09-08 Suicide Risk Reduction dated October 1, 2008.

7. FOLLOW-UP RESPONSIBILITY: Chief, Behavioral Health Service

Concur/Nonconcur Concur/Nonconcur

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Attachment2 (2)

Distribution: All services via Outlook

QB/jcz

PRELIMINARY RISK ASSESSMENT QUESTIONS

(Derived from National Clinical Reminder Suicide Screening Questions)

1) Are you feeling hopeless about the present or future?

a. If yes, have you had thoughts about taking your life?

b. If yes, when did you have these thoughts?

Date:

2) Do you have a plan to take your life?

Comments:

3) Have you ever had a suicide attempt?

Description/Dates:

4) Paying close attention to questions 1a. and 1b.

a. Patient does not exhibit _____ no further assessment is required.

b. Patient exhibits signs of _____ and full assessment is indicated.

Determination of a positive Preliminary Risk Assessment should be a clinical decision based on the Veterans answers to the Preliminary Risk Assessment questions.

Attachment A

DETAILED SUICIDE RISK ASSESSMENT

(Determined During Face-to-Face Evaluation)

CURRENT RISK FACTORS

[ ] Patient (suicidal ideation) [ ] Patient (previous suicide attempt(s)) [ ] Family (attempts among first degree relatives) [ ] Mental health diagnosis [ ] Sleep disturbances (unable to sleep or sleeping all the time) [ ] Impulsivity/poor self-control [ ] Recent discharge from an inpatient psychiatric unit [ ] Other:

*Describe any checked items:

Social/demographic risk factors (check all that apply):

[ ] Elderly (65+) [ ] Young adult (15-24) [ ] Unmarried [ ] White [ ] Male [ ] Living alone [ ] Current alcohol and/or drug use [ ] Chronic physical disorder or pain [ ] Owns a firearm [ ] History of abuse (physical, sexual, or emotional) [ ] Same sex sexual orientation [ ] None identified

Current psychosocial stressors/recent losses (check all that apply):

[ ] Marriage [ ] Home and family life [ ] Employment [ ] Health (especially a newly diagnosed problem or worsening symptoms) [ ] Finances [ ] Legal [ ] Other:

[ ] None identified

*Describe any checked items:

Attachment B

PROTECTIVE FACTORS

[ ] Positive Future Plans [ ] Positive Social Support [ ] Sense of Responsibility to Family/Significant Other [ ] Children in the Home, Pregnancy [ ] Cultural/Religious/Spiritual Beliefs [ ] Life Satisfaction [ ] Intact Reality Testing Ability [ ] Positive Coping Skills [ ] Positive Problem-Solving Skills [ ] Positive Therapeutic Relationship [ ] Other:

*Describe any checked items:

OVERALL ASSESSMENT

Given the Veteran's presentation at the time of this assessment and considering the above noted risk and protective factors, in my clinical judgment the Veteran’s current risk potential for suicidal behavior is:

[ ] LOW: Veteran judged NOT to be at significant risk for self harm (Plan of Care MUST be completed)

[ ] MODERATE: Veteran judged to be at increased risk of suicide but not imminently dangerous to self (Plan of Care MUST be completed)

[ ] HIGH: Veteran judged to be at imminent risk for self harm (Plan of Care MUST be completed)

PLAN OF CARE OPTIONS (based on level of assessed risk)

LOW: Patient judged NOT to be at significant risk for self harm (Check ALL that apply)

[ ] Education provided to Veteran and/or family member/significant other regarding suicide risk/protective factors, and warning signs of suicidal behavior

[ ] Provided (in writing) Veteran and/or family member/significant other with the following telephone numbers for use should emergency/crisis situation arise:

[ ] VA contact names and phone numbers (both during and after working hours) [ ] Specify responsible VA contacts:

[ ] National Suicide Hotline (1-800-273-TALK) [ ] Local Suicide Hotlines [ ] 911 [ ] Local ER Numbers [ ] Other:

[ ] Recommend reassessment for suicide risk after any significant change in situational stressors or Veteran presentation

MODERATE: Patient judged to be at increased risk of suicide but not imminently dangerous to self (Check ALL that apply)

[ ] Education provided to Veteran and/or family member/significant other regarding suicide risk/protective factors, and warning signs of suicidal behavior

[ ] Provided (in writing) Veteran and/or family member/significant other with the following telephone numbers for use should emergency/crisis situation arise:

[ ] VA contact names and phone numbers (both during and after working hours) [ ] Specify responsible VA contacts:

[ ] National Suicide Hotline (1-800-273-TALK) [ ] Local Suicide Hotlines [ ] 911 [ ] Local ER Numbers [ ] Other:

[ ] Family member/significant other informed and involved in plan

[ ] Mental health staff contacted and included as identified signer

[ ] Veteran and/or family member advised to limit Veteran access to means of suicide(firearms, knives, medications, household poisons, etc.) from home or other access points (car, garage, shed, etc.)

[ ] Specify types, number, and availability of weapons and other known means reported:

[ ] Specify actions to be taken to limit Veteran access:

[ ] Mental health consult(s) placed Specify clinic(s)/program(s):

[ ] Increased outpatient follow up:

[ ] by phone [ ] in person Responsible clinician:

Frequency of follow up planned:

Date/time of next follow up appointment:

[ ] Voluntary Admission considered and:

[ ] Veteran admitted [ ] Not implemented based on clinician judgment [ ] Specify reason(s) for clinical decision to NOT admit:

[ ] Veteran declined recommended intervention and, based on clinical judgment, does not meet criteria for involuntary commitment

HIGH: Veteran judged to be at imminent risk for self harm (Check ALL that apply)

[ ] Family member/significant other informed and involved in plan

[ ] Escorted the Veteran to ER for psychiatric evaluation (pt. directly observed until evaluated by ER physician and, if admitted, by admitting physician)

[ ] Veteran directly admitted to appropriate Psychiatry Inpatient Service (pt. directly observed until evaluated by admitting physician)

[ ] Involuntary commitment procedures initiated

[ ] Other: