S02 - Attachment 16 - COS-81 Suicide Prevention Policy.pdf

DEPT. OF VETERANS AFFAIRS

BLACK HILLS HEALTH CARE SYSTEM

COS-81

September 07, 2017

SUICIDE PREVENTION POLICY

1. PURPOSE:

To establish and publish policy and procedure for identifying mitigating, and managing suicide risk of the entire Veteran community and enrolled Veterans served by the Department of Veterans Affairs Black Hills Health Care System 0/A BHHCS).

2. POLICY:

It is the policy of the VABHHCS to diligently assess for and identify risk factors and warning signs for suicide, and to provide intervention for Veterans experiencing suicide risk with the same urgency as any other life-threatening condition. All medical center personnel are responsible for identification and reporting of potential suicide risks, including environmental conditions and Veteran behaviors. Clinical staff is expected to ensure the safety of Veterans, report observations to the providers, document those observations in the Veteran's electronic medical record and document suicidal related behaviors as a Suicide Behavior Report (SBR).

DEFINITIONS:

A. Suicide Prevention Team (SPT) includes the Suicide Prevention Coordinator (SPC), Suicide Prevention Case Manager (SPCM), the Suicide Prevention Program Support Assistant (SP PSA) (in all non-clinical and administrative functions) and when pertinent, the Veteran.

B. Suicide Prevention Committee: is an interdisciplinary committee of providers and clinical staff including; MD/DO, APRN/NP, PA, PhD/PsyD Psychologist, Nursing (RN), Social Work (MSW/DSW), Counselors and Chaplaincy (Residents/Chaplains).

C. Clinical Staff: Includes MD/DO, APRN/NP, PA, PhD/PsyD Psychologist, Nursing (RN), Social Work (MSW/DSW), Dental (Dentists), Audiologist, Optometrist, Podiatrist, Addiction/Music/OccupationaI/PhysicaI/ Recreational/Respiratory/SpeechNocational Rehabilitation Therapy (Therapists), Chaplaincy (Residents/Chaplains), Dietetics (Dieticians), Pharmacy (Pharmacists), and including those professionals requiring clinical oversight/supervision for licensure) or other allied healthcare professionals who by virtue of educational background and privileging and/or scope of practice have been determined by the facility to be capable of assessment and diagnosis. The guidelines in this policy will also apply to other healthcare professionals who perform assessments under the direction, guidance or supervision of an MD/DO, APRN, PhD/PsyD Psychologist (e.g., Nurse Practitioner student and unlicensed Psychologists), and to all Psychiatry Residents and Psychology Interns.

D. Non-Clinical Staff: Includes staff not included under clinical staff definition that work in but is not limited to the following areas: Office of the Director, Business Office, Facilities Management, Nutrition Food Services, Canteen Services, Human Resource Management, Information Management, Voluntary Services, Education, Mental Health and Primary/Specialty/Extended Care.

E. Suicide Completions: Death from self-inflicted injury, poisoning or suffocation where there is evidence that the act was intentional and led to the Veteran's death. The concept of suicide requires that the action was self-inflicted and the Veteran had the intent (purpose, aim or goal) of death or end of life.

F. Suicide Attempts: A potentially self-injurious behavior with a nonfatal outcome for which there is evidence that the Veteran had any intent to kill himself or herself, but failed, was rescued or thwarted, or changed one's mind. A suicide attempt may or may not result in injuries.

G. Undetermined Suicide-Related Behavior: A self-inflicted potentially injurious behavior where intent is unknown. This would include Veterans who are unconscious, psychotic, and delusional, demented or for some reason unable to convey their intent.

H. Suicidal Ideation: Any thought of engaging in suicide-related behavior. For the purpose of these definitions, suicide ideations are thoughts that are not linked to actions.

I. Suicide Plan: A proposed method of carrying out a design that can potentially result in suicide related behaviors; or a systematic formulation of a program of action that will potentially lead to suicide related behaviors.

J. Self-Harm Behavior: A self-inflicted potentially injurious behavior for which there is evidence that the Veteran did not nor does not intend to end one's own life.

K. Veteran Health Questionnaire (PHQ-2) : An empirically supported 2-item Depression screen (Appendix-A).

L. Veteran Health Questionnaire (PHQ-9) : An empirically supported 9-item

Depression and Suicide screen (Appendix-D).

M. Suicide Behavior Report (SBR): The progress note in the electronic medical record by which VA providers/staff document suicide attempts, suicides, and undetermined suicide-related behavior and inform the facility Suicide Prevention Team of the event (Appendix E).

N. Category I High Risk for Suicide Veteran Record Fag (PRF): A visual tool displayed in the electronic medical record with the primary purpose of communicating to VA staff that a Veteran is currently experiencing risk factors that put him/her at high risk for suicide.

0. Suicide Risk Assessment (SRA): A clinical evaluation tool designed to assist in identifying and documenting necessary information to help determine a Veteran's current risk level and care needs (Appendix G).

P. Suicide Safety Plan (SSP): A prioritized, written list of coping strategies and sources of support for Veterans to use during or preceding suicidal or other emotional crisis (Appendix B).

Q. Survivor of Suicide: A family member or friend of a person who died by suicide.

R. No current identifiable risk for suicide: Veteran currently has no suicidal thoughts, plans, or intent. Veteran has very strong protective factors and few or no risk factors. Veteran is doing well at the current level of care or does not require mental health services at this time.

S. Low Risk for Suicide: Suicidal Ideation of limited frequency, intensity and duration, no identifiable plans, no intent, mild dysphoria/symptoms, good self-control, few risk factors, and identifiable protective factors. The Veteran agrees to abstain from use of drugs or alcohol, goes to detox, agrees to seek help, or accepts referral(s).

T. Moderate Risk for Suicide: Frequent suicidal ideation with limited intensity and duration, some specific plans, no intent, good self-control, limited dysphoria/symptoms, some risk factors present, and identifiable protective factors, seeks help, or accepts referral(s). The provider will assist the Veteran, identify how to remove the means to suicide and identify alternative coping strategies. Veteran is able to complete and follow a safety plan. Veteran may benefit from an increase in level of care.

U. High Risk for Suicide: Frequent, intense and enduring suicidal ideation, specific plan with means available and intent present, evidence of impaired self-control, severe dysphoria/symptoms, multiple risk factors present without protective factors present, and ability to carry out safety plan is in question at the time. Veteran may require a higher level of care, such as hospitalization or residential treatment.

V. Imminent risk for suicide: Veteran currently has active intent, plan, and means to commit suicide or has already engaged in suicidal behavior. There are no protective factors in place likely to prevent suicidal behavior. Veteran requires immediate intervention, such as health and welfare check by local authorities and/or hospitalization to ensure safety.

W. Protective Search: Check for objects that may be harmful to Veterans or staff, including a check of belongings, pockets, and immediate area.

X. Social Media: Various online technology tools that enable people to communicate easily via the Internet to share information and resources often in a public or non-private venue. Social media may include text, audio, video, images, podcasts and other multimedia communications.

3. PROCEDURES:

A. Screen for Suicide Risk can be completed by all providers and clinical staff.

The Veteran Health Questionnaire-2 (PHQ2) will be administered at intake/admission, transition of care, discharge, and at regular intervals as determined by each service line and when clinically indicated (e.g., when depressive symptoms or suicide warning signs and risk factors are noted). Upon a score of 2 or more with the PHQ-2, the Veteran Health Questionnaire-9 (PHQ-9) will then be completed for further determination of depression and possible suicide. Upon a score of 4 or more and/or a positive answer on the last question of the PHQ-9 a suicide risk assessment must be completed. The Suicide Risk Assessment template progress note is available to complete by typing in the note title, "Suicide Risk Assessment." (Refer to ATTACHMENT A, D, and G).

B. Mental Health Inpatient Suicide Risk Assessment will be completed by any

Locked Inpatient Psychiatric unit provider or clinical staff for Veterans determined by the clinical staff to be at a high risk for suicide. The clinical staff will conduct a suicide risk assessment; using the template provided or documenting within his/her electronic progress note (Appendix G).

C. Safety Plans: are highly recommended for use with any Veteran expressing or displaying suicide risk factors or any degree of emotional distress. However, they are mandatory for Veterans with a High Risk for Suicide PRF assigned to their medical record. Safety plans are not clinical assessments, and can therefore be completed by any staff member in contact with a Veteran in a clinical setting. Safety plans must:

(1) Be a collaborative effort between the Veteran and the provider or other staff member. Family members, friends, or other supportive individuals identified by the Veteran should be included in this process whenever possible.

(2) Be documented in the electronic medical record: The note must be independent of any other progress note and may not be attached to a clinical progress note.

(3) Be given to the Veteran in paper form prior to leaving the hospital or clinic on that day.

(4) Include the SPT as additional signer(s) to the note, as well as the supervising provider (if completed by a staff member who is not a provider, as defined above).

D. Suicide Behavior Report (SBR): is used to report and document suicide attempts, suicides, and undetermined suicide-related behavior. Such events must be reported to the SPT within one business day of learning of the event. If more than one provider/staff member is informed of the event, it is preferable that the person with the most direct, thorough knowledge of the event complete the SBR. Documentation of the event must be completed using the progress note title "SUICIDE BEHAVIOR REPORT" in the electronic medical record. The SPT and Safety Manager(s) must be identified as additional signers to all SBRs. Providers/clinical staff are encouraged to contact the SPT for assistance in completing the SBR if needed.

E. Clinical Judgment:

(1) Suicide risk assessments must be conducted and documented in the electronic medical record: using the template provided or documenting within their electronic progress note.

(a) Whenever a Veteran is seen for the first time as an outpatient; as part of the History and Physical examination at the time of admission to inpatient psychiatry or residential programming.

(b) Prior to discharge from inpatient psychiatry or residential programming;

when suicide risk has been identified within the rationale for admission and, a Suicide Safety Plan template progress note must be documented in the electronic progress notes.

(2) A suicide risk assessment requires the provider and clinical staff to address a number of specific areas that are pertinent to making a clinical judgment about a Veteran's suicide potential. Suicide risk must be documented in the electronic medical record (Appendix F and G).

(3) The Suicide Risk Assessment reflects an active assessment process in which the provider and clinical staff asks specific questions about suicide and elicits relevant responses from the Veteran (Appendix G).

(4) A clinical judgment that a Veteran is at high risk for suicide must be accompanied by a change in treatment plan that is consistent with the assessed level of risk and attempts to address the Veteran's safety needs in the most appropriate treatment setting possible. The provider needs to consider completion of ongoing Suicide Risk Assessments, Suicide Safety Plans, appropriate diagnosis, medication management, frequent follow up appointments, involving Veteran's significant others in care planning, and limiting the Veteran's access to means to self-harm when possible.

(5) In those instances, when a Veteran is failing to improve, is exhibiting worsening depressive symptoms, or is making repeated or unscheduled visits to the clinic or urgent care, the clinical staff can seek consultation with the psychiatric provider, Psychiatrist of the Day (POD), or another clinical staff to determine appropriate clinical interventions. Consultations must be documented using a progress note in the electronic medical record.

(6) Clinical staff and providers will document the status of suicide risk at Veteran visits being alert for any changes in the Veteran's psychiatric and psychosocial status that would signal the need for a more thorough and more active suicide risk assessment. When a Veteran is identified to have high suicide risk, a Suicide Safety Plan template progress note will be completed. (Appendix B)

F. No Show Appointment Follow Up: No-Show appointments are to be reported to

SPT. When unable to ascertain the safety of the Veteran, SPT collaborates with the provider and clinical staff regarding potential welfare check and documents in CPRS.

G. Veteran Record Flags (PRF) Category I- High Risk for Suicide:

(1) Communicates to all Veterans Health Administration (VHA) staff that a

Veteran is at high risk for suicide and the presence of a flag should be considered when making treatment decisions.

(a) It is important to ensure that usage of the PRF is limited to only those

Veterans at high risk, and only for the duration of the increased risk for suicide. The PRF is removed as soon as it is clinically indicated to do so.

The decision regarding removal of the PRF is done in conjunction with the associated provider, clinical staff, suicide prevention committee, and the SPT. (Refer to ATTACHMENT C)

(2) Veterans having a High Risk for Suicide PRF must meet one of the following criteria:

(a) Clinically assessed as high risk for suicide by appropriate clinical staff.

(b) Veteran has had a suicide related behavior (action versus ideation) that the provider, clinical staff, suicide prevention committee, and SPT deem to be of immediate and active concern.

(3) The SPT will consult with the provider, clinical staff and suicide prevention committee on the rationale and review the process for the flag. The SPC in consultation with the suicide prevention committee will place the PRF High Risk for Suicide Flag. Continuance and inactivation will be conducted by the SPT in consultation with the suicide prevention committee following necessary clinical direction.

(4) The SPT, in conjunction with the associated provider, clinical staff and suicide prevention committee will review the flag every 90 days for a determination regarding removal or continuation of the flag.

(5) The absence of a High Risk for Suicide PRF on a Veteran record does not indicate that the Veteran is not at risk for suicide. In the event of concerns for suicide risk, referrals are to be made to the SPT, POD and/or by mental health consult.

H. Category I High Risk for Suicide Veteran Record Flag (PRF): is intended to address immediate clinical safety issues, and their use is limited to those Veterans believed to currently be at high risk. The PRF can be activated and inactivated only by the facility's SPT in consultation with the suicide prevention committee. Veterans with a High Risk for Suicide PRF assigned to their chart must:

(1) Have a written safety plan in their hand before leaving the hospital or clinic on the day the risk is first identified, following procedure outlined in section 5.c.

(2) Have had a discussion with the appropriate provider about PRF assignments and discussion with Veterans who must be agreeable to receiving additional support. Exceptions can be made on a case by case basis if the Veteran is not immediately available for this discussion (ex -being currently admitted to an outside facility).

I. Follow up for Veterans with High Risk for Suicide PRF: Veterans with an active

PRF must:

(1) Be seen/contacted by a provider and/or clinical staff within 7 calendar days of the flag assignment or discharge date (if hospitalized). The Veteran must be contacted by telephone and seen in clinic within 14 days if a face-to-face appointment is not possible within 7 days.

(2) Have at least weekly contact with a provider and/or clinical staff for first four weeks after flag activation, and at least every 30 days thereafter, until the flag is inactivated. ·

(3) Be contacted by a provider and/or clinical staff (as defined above) for any no-show to mental health appointments. At least three attempts to contact the Veteran (by phone in most cases) over three business days must be made and documented in the medical record. The clinical staff scheduled to see the Veteran is responsible for the first contact attempt, at minimum.

The SPT should be contacted to discuss and determine the most appropriate follow up for those Veterans not contacted within three attempts. Contact by clerical staff or other non-clinical personnel does not qualify as sufficient follow up for Veterans with an active High Risk for Suicide PRF.

(4) Be contacted by mail if they fail to respond to three voice mails left over the course of three business days.

(5) Receive monthly mailing from the SPT.

(6) Have the PRF reviewed by their provider(s), Clinical Staff, Suicide Prevention Committee, and the SPT at least every 90 days to determine whether it should be reactivated for another period of 90 days or inactivated.

The High Risk for Suicide PRF must be inactivated when provider(s)/clinical staff no longer perceive suicide risk as "high" or "imminent," based on suicide risk assessments documented in the medical record. PRFs may be reactivated if high risk returns, but cannot remain active indefinitely in the absence of current risk factors. PRFs for Veterans currently requiring mental health contact less than monthly will be inactivated at the end of the 90-day review period unless extenuating circumstances exist.

J. Transportation Considerations:

(1) Ensuring Veterans' immediate safety needs and the most appropriate setting for treatment are addressed. If there is any reason to believe that a Veteran is in imminent danger or poses a grave danger to him/herself, and/or if the person is uncooperative, combative or otherwise unwilling to seek help and a sense of acute danger is present, never leave Veteran alone and call 7177 from within the Fort Meade campus, for Hot Springs campus call 2020, or 911 if located off VA BHHCS grounds, in the community, or at a VA CBOC.

(2) For those situations where the Veteran is being seen in the community or at a VA CBOC presenting with high but not imminent risk of suicide, they should be supervised 1:1. If hospital admission is deemed necessary, it is recommended that a secure car or ambulance be used to transport the Veteran to the nearest hospital with an emergency department.

(3) If Veteran refuses recommended transport and is transported by family, self, VA staff, other support person, or other means, that choice must be documented in medical record noting refusal to use recommended transport. When available, Veteran will sign an IMED consent that he/she has chosen not to follow medical advice. If Veteran refuses recommended level of care and transportation and does not have the capacity to make the decision, a temporary hold must be initiated following policy.

(4) Coordination of care with community hospitals to verify admission/arrival, reason for referral, and to coordinate discharge planning must be completed.

K. Telephone Calls Involving Threatened Suicide:

(1) When the switchboard operator receives an incoming telephone call from a Veteran threatening suicide, the operator will forward the call to the Fort Meade Inpatient Psychiatric Unit at extension 7132.

(2) If the switchboard operator is aware of the suicide threat, the operator will stay on the line and document the phone number on the call if possible and until it is determined that the call has been received by the RN on Inpatient Psychiatry. Tracing of the call may be required and the Nurse will alert the staff on duty to take the necessary steps to trace the call.

(3) The RN will complete an Incident Report in Electronic Event Reporting

System, attach a completed Progress Note and forward it to the SPC and Safety Manager(s). The nurse will also contact the POD and forward the progress note to the POD for an additional signature and review.

(4) The RN will notify local authorities.

L. Welfare Check: Clinical staff may contact local law enforcement and request a welfare check if, in their clinical opinion, the Veteran is in imminent danger of suicide and there is no other reasonable, safe manner to establish the Veteran's safety.

Clinical staff must document that a welfare check was requested in the Veteran's electronic medical record. Documentation should include which agency was contacted and the outcome of welfare check. The SPT and Privacy Officer must be added as additional signers to this documentation.

4. RESPONSIBILITIES:

A The Health Care System (HCS) Director has overall responsibility for the development of HCS policies and procedures on the prevention and management of Veterans with suicidal behavior.

B. Chief of Staff is responsible for implementing HCS policy and reporting to the

Director unusual incidents in the management of Veteran care. He/she is responsible for reviewing individual suicide Root Cause Analysis (RCA) and cumulative suicidal behavior data submitted quarterly by the SPT, with approval of recommendations as appropriate.

C. Associate Chief of Staff for Mental Health (ACOS/MH) will ensure all safety concerns in the design of inpatient psychiatric units are adequately addressed. In collaboration with the Chief of Staff, ACOS/MH, SPC, and the Privacy and Security Office (PSO) will coordinate regularly scheduled environmental rounds on inpatient psychiatric units to identify elements of the architecture or care processes that may lead to suicidal behavioral and follow-up as needed. The ACOS/MH has overall responsibility for establishing and communicating the policies and procedures pertaining to Veteran suicides and suicide attempts.

D. Education Director is responsible for providing, at the direction of the Chief of Staff, and in conjunction with the SPC, an ongoing active program of continuing education on the prevention and management of suicidal behavior that will provide appropriate levels of training for all staff throughout the Health Care System (HCS) who have contact with Veterans.

E. The SPT functions to monitor the care for Veterans at high risk for suicide and serves as advisor to service line and facility leadership, program managers, and staff concerning suicide prevention policies and procedures, as well as suicide prevention strategies for individual Veterans. The SPT also serves as a resource for the facility, Veterans, and the community as a whole.

(1) SPT duties will generally include administrative tasks, program oversight, and responsibilities related to the Veterans Crisis Line, case management and care coordination for high risk Veterans. SPT members must be familiar with all aspects of the program and must be able to provide coverage of essential functions in the absence of other team members.

(2) SPT will initiate a "Heads Up" form within 2 hours of notification of a suicide attempt and an "Issue Brief' as appropriate within 24 hours of notification.

(3) The SPT will assist providers with identifying Veterans at high risk for suicide and with managing the care of those Veterans. Category I High Risk for Suicide Veteran Record Flags (PRF) will be used to identify these Veterans and to notify personnel providing care of the increased risk. The SPT will assist with direct Veteran care and case management as needed, but does not assume the role of Mental Health Treatment Coordinator for these Veterans. Refer to section 5.e. of this policy for full procedures related to the PRF.

(4) The SPT will ensure the suicide prevention policy is up to date and in compliance with national directives and any other requirements. The SPT will provide consultation on the development and implementation of policies and procedures related to suicide across the health care system as requested.

(5) The SPT will provide educational outreach and support to community organizations and other stakeholders as such opportunities arise.

(6) The SPT will assist staff responsible for the monitoring of social media websites with follow up on comments or postings to such sites causing concern for suicide risk.

(7) The SPT is responsible for tracking all suicide attempts assessed and flagged as high risk for suicide through the use of the "Suicide Behavior Report" template progress note. The events will be reported via the SPC to the Center of Excellence for Suicide Prevention utilizing the web-based Suicide Prevention Application Network (SPAN). The SPT will ensure all Veterans on the medical center tracking list are followed closely by the appropriate provider and treatment team on a regular basis. The SPT will also track any no-show appointments of these Veterans and follow up with the treatment teams as soon as possible to ensure follow up (Appendix E).

(8) The SPT, in collaboration with the Education Director, is responsible for developing and implementing annual training for designated HCS employees whose job assignment increase their likelihood of telephone contact with potentially suicidal Veterans. Targeted employees will include staff working in telephone triage, Health Care System operators, the Medical Officer of the Day (MOD), Mental Health staff, and clerical staff working in outpatient clinic areas. Other staff may participate in this training if deemed desirable by the Chief of Staff, ACOS/MH or HCS supervisory personnel. Supervisors/Service Line Directors are responsible for ensuring staff have access to training on an annual basis.

(9) The SPT will develop and implement an ongoing education plan for providers, Veterans, families, and members of the community on risk factors and warning signs for suicide and treatment options.

(10) The SPT is responsible for tracking and trending all cases of suicide and suicide attempts by inpatient and outpatient, and providing this data on a quarterly basis to management and services/service line directors through the Mental Health Executive Council and the Clinical Executive Council. All services/service line directors are responsible for using this data to evaluate and improve clinical processes.

(11) The SPT will track and monitor Veterans at high risk for suicide for a period of 90 days. The SPC may make telephone contact, as needed to ensure the continuum of care and will establish a US mail contact program with Veterans at high risk for suicide. The SPC will work with clinical providers to ensure Veterans are informed of monitoring and contacted by the SPT.

(12) The SPT is responsible for providing timely response to consultations received from the Veterans Crisis Line (VCL). Follow up to VCL consults must be initiated within one business day of the call and documented in

CPRS.

(13) The SPT will report all suicide attempts and suicides to the Center of

Excellence for Suicide Prevention, utilizing the web-based Suicide Prevention Application Network (SPAN). A Behavioral Health Autopsy and Family Interview Form must be completed for each known suicide and submitted (within 30 days of learning of the suicide) to the National Suicide

Prevention Office in accordance with 1ON memo to Network Directors dated 12/11/2012.

F. Safety Manager(s), and SPT will be included as signers on all SBRs for review, in addition to the Veteran's treatment team.

G. Suicides or suicide attempts occurring on VA grounds or otherwise meeting the definition of 'sentinel event' should be reported to the SPT, AOD, and Safety Manager(s). Rapid communication is vital to suicide prevention efforts. Any VA BHHCS staff might be the first contact of a suicidal Veteran. SPT cell phone (605) 490- 0098 is answered from 8:00 AM. - 4:00 P.M. Monday through Friday excluding holidays. Outside of business hours the call will transfer to the Veteran's Crisis Line.

Calling is the timeliest way to notify the Suicide Prevention Team to act. Another action is to also contact the AOD after a suicide attempt or completed suicide on station. This will facilitate faster release of information to our executive staff. Document event as a Suicide Behavior Report and report using the electronic Veteran Event Reporting System.

H. All service line directors are responsible for ensuring safe Veteran care, appropriate and timely documentation in the Veteran's electronic medical record, and for providing consultation to the interdisciplinary treatment team. All clinical services/service line directors are responsible for ensuring pertinent providers under their supervision are aware of the contents of this policy and are competent in carrying out the designated procedures. Supervisory staff is responsible for ensuring all designated employees complete training on an annual basis and include it as part of employees' annual competency plan.

I. Clinical staff are responsible for a careful analysis of the suicide risk potential for each Veteran. This applies to those Veterans admitted to beds within the Mental Health Service Line as well as non-psychiatric areas when indicated. This also applies to active outpatients served by the VA BHHCS. Clinical staff have the responsibility for documenting the level of suicidal potential. Veterans identified by the clinical staff to have a high risk for suicide and have suicidal ideation as a basis for admission will have a completed Suicide Safety Plan template progress note, which identifies the SPT as additional signer(s). Depending on the level of suicide potential determined by the clinical staff, the clinical staff will document in the electronic medical record, completing the appropriate progress note. In the case of a suicide attempt, a Suicide Behavior Report will be completed and the SPT and Safety Manager(s) placed as additional signers. The need for placement or removal of the PRF will be determined by the Suicide Prevention Committee, SPT, and clinical staff providing Veterans care. The clinical staff designated in this policy are responsible for carrying out these required procedures in order to ensure the safety of Veterans (Appendix B, E, F and G).

J. Treatment Team Members are responsible for reporting high risk for suicide behaviors in a timely manner to clinical staff to ensure the immediate safety of the Veteran. They are responsible for documenting their observations/assessments in the

Veteran's electronic medical record in a timely manner. Team members are also responsible for notifying their supervisor of suicide related events.

K. Providers and/or clinical staff are responsible for:

(1) Completing Suicide Risk Assessments.

(2) Identifying and reporting Veterans at high risk for suicide.

(3) Follow-up on high risk Veterans.

(4) Updating treatment plans including ongoing monitoring for suicidality, periods of increased risk, and missed or cancelled appointments.

(5) Ensuring appointments are set up for follow up as appropriate.

(6) Ensuring appropriate diagnosis is present.

(7) Addressing medication management.

(8) Addressing means reduction.

(9) Attaining collateral information including family involvement with appropriate releases as needed. Checking for next of kin and emergency phone numbers on cover sheet in the electronic record.

(10) Facilitating the development of a Suicide Safety Plan.

(11) Ensuring Veterans are assessed for suicide risk for unplanned discharges from inpatient or residential treatment programs and safety plans are established and updated prior to these discharges. Safety plans include follow up appointment the next business day, follow up appointment within 7 business days, and phone contact within 24 hours.

(12) Assessing for suicide risk and updating suicide safety plan as appropriate prior to off campus or overnight pass during residential treatment programs.

(13) Coordinating with appropriate staff when Veteran is at risk for suicide or exhibiting suicide related behaviors; and completing SBR in the electronic medical record.

(14) Ensuring Veterans have contact information for any emergency resources necessary during their course of treatment and these resources are placed in the Veteran safety plan. These resources may include, but are not limited to, phone numbers for the primary provider, mental health treatment coordinator, SPT, Veterans Crisis Line, local/private providers, local emergency departments, and family/friends. (See section 5.c. of this policy for procedure related to safety plans.)

(15) Ensuring that clinic, office, and cell phones equipped with voicemail use the following voicemail greeting: ""HELLO. YOU HAVE REACHED THE

PHONE OF [INSERT NAME AND TITLE]. IF YOU ARE HAVING A

MEDICAL OR MENTAL HEALTH EMERGENCY, HANG UP AND DIAL

911. IF YOU ARE HAVING THOUGHTS OF SUICIDE, PLEASE HANG

UP AND CALL 1-800-273-8255, THEN PRESS 1 AT THE PROMPT TO

REACH THE VETERANS CRISIS LINE. THAT NUMBER AGAIN IS 1,

800, TWO, SEVEN THREE, EIGHT, TWO, FIVE, FIVE, AND THEN

PRESS 1 FOR THE VETERANS CRISIS LINE. Otherwise, please leave a brief message and I will return your call when I am able during regular business hours." When a provider is on leave, the message must be updated to include the name and number of the person(s) providing coverage.

(16) Ensuring the immediate safety of any Veteran presenting with risk factors indicating high or imminent risk of suicide, or other self-harm behavior.

Provider response to such situations will include:

(a) Removal of any medical supplies, equipment, and other items that could potentially be used as weapons from the environment.

(b) Provision of 1:1 supervision by an appropriately trained staff member until the Veteran can be escorted or transferred to an appropriate level of care with a warm hand off.

(c) Contacting Fort Meade VA Police at (ext. 7777), Hot Springs VA Police at

(ext. 2020), or 911 (if outside the hospital), if needed, to ensure the safety of the Veteran and staff. Following Transportation procedures in Section H of this policy.

(d) Specific documentation of all measures taken to mitigate suicide risk factors.

L. Facility Chief Information Officer is responsible for ensuring the standard telephone tree logic at each medical center is configured in such a way that callers have the option to be connected to the crisis line by pressing the number 7.

Approved "Welcome Greeting" language: Welcome to the VA Black Hills Health Care System. If you are having a medical or mental health emergency, please hang up and dial 911. If you are having thoughts of suicide, press 7 now to be connected with the Veterans Crisis Line. Or, you may call 1-800-273-8255, then press 1. If you know your party's extension, dial it at any time.

M. All VA BHHCS Employees are responsible for:

(1) Recognizing risk factors and warning signs for suicide and following established emergency procedures for their work setting to ensure Veteran safety.

(2) Ensuring any Veteran experiencing risk factors or warning signs for suicide and/or expressing suicidal ideation receives a full assessment by a qualified clinical staff.

(3) Notifying the SPT of any known suicidal behavior of a Veteran and notifying

VA Police of any suicidal behavior which occurred on VA property.

(4) Completing Suicide Prevention training as assigned and maintaining knowledge related to SAVE.

(a) All health care clinical staff must complete the required suicide risk and intervention training module in TMS and pass the post-test within 90 days of entering the position.

(b) All non-clinical staff will complete SAVE Training during New Employee

Orientation (NEO).

(c) All VA BHHCS personnel must complete annual suicide prevention refresher training in TMS.

5. REFERENCES:

A. Mental Health Initiatives memo, Deputy Under Secretary for Health Operations and Management.

B. Stanley, B & Brown G.K. (2008). Safety Plan Treatment Manual to Reduce

Suicide Risk: Veteran version. Washington, D.C.: United States Department of Veterans Affairs.

C. The Joint Commission 2016 National Veteran Safety Goal #15.

D. Department of Veterans Affairs Office of the Inspector General.

E. Implementing VHA Mental Health Initiatives for Suicide Prevention, May 10, 2007.

F. Veterans at High Risk for Suicide Memorandum, April 24, 2008.

G. Suicide Risk Assessment Guide Reference Manual, online at http://www.mentalhealth.va.gov.

H. VHA Directive 2008-036 Use of Veteran Record Flags to Identify Veterans at

High Risk for Suicide.

I. Under Secretary for Health's information Letter New JCAHO Performance Requirement for Mitigating the Risk of Suicide, IL 10-2006-013, December 11, 2006.

J. VHA Directive 2010-053 Veteran Record Flags, dated December Corrected

Copy Dated 2/13/2011.

K. VHA Handbook 1050.1 VHA National Veteran Safety Improvement Handbook, dated March 4, 2011.

L. ICVAHCS Medical Center Memorandum 16-113 dated June 27, 2016.

6. RESCISSION:

Suicide Risk Reduction Program April 2016.

7. DATE OF COMPLETE REISSUANCE:

August 18, 2018, and to be reviewed annually.

8. FOLLOW-UP RESPONSIBILITY:

Suicide Prevention Team/Mental HealthNA BHHCS auclAo.-- u CU-1 Sandra Hors kn, MBM Director http://www.mentalhealth.va.gov/

APPENDICES:

A. Veteran Health Questionnaire 2 (PHQ2) B. Suicide Safety Plan C. Veteran Record Flag Category II High Risk for Suicide D. Veteran Health Questionnaire 9 (PHQ9) E. Suicide Behavior Report F. Suicide Risk/Interventions G. Suicide Risk Assessment H. VABHHCS Response to Suicidal Caller

Appendix A - VETERAN HEALTH QUESTIONNAIRE 2 (PHQ2)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things.

0 Not at all 1 Several Days 2 More than half the days 3 Nearly every day

2. Feeling down, depressed or hopeless.

1 Several days

Appendix B - SAFETY PLAN

I

I

SAFETY PLAN:

My personal plan for getting through a crisis safely.

Step 1: Warning signs.

It is important to recognize when you are getting into trouble. Ask yourself:

1. What changes do I notice in myself when I feel extremely distressed?

2. What do other people say they notice when I feel this way?

These might include thoughts, images, moods, behaviors, or physical reactions. List your personal warning signs in the blanks below. When these things happen, it is time to use your safety plan.

Warning signs: I

1.

2.

3.

Step 2: Healthy, fun activities that help take my mind off of my stress.

These are things that you can do on your own, often without contacting another person. Ask yourself:

1. What are the things I enjoy most?

2. What used to be fun for me that I need to start doing again?

List your ideas in the blanks below. Make sure these activities are going to be helpful instead of causing more problems. If they improve the situation and help you feel better, that's great. If they don't, go on to step 3.

Healthy, fun activities that help take my mind off of my stress:

2.

3.

Step 3: People and places that provide distraction.

If you continue to feel overwhelmed, stressed, or unsafe, it is time to contact a positive person or go somewhere that is comforting and supportive. The people you list in this step do not have to be those who you share intimate details with; they are simply fun, safe people to be around. List several in case your first contact is not available. Ask yourself:

Who helps me relax?

Where are my favorite places to unwind?

Peo pJe and places that provide distraction: I

1. Name Phone

2. Name

3. Name PIace

Step 4: People who can help me resolve a crisis.

If the people or places in Step 3 aren't enough, the next step is to contact someone for help. These are people who you are comfortable talking to about the problems or issues you are dealing with. These are people who know you well, and who are willing to help you anytime you need them. These often include family members, close friends, sponsors, and religious or spiritual leaders. Ask yourself:

Who is most willing to listen to my struggles and help me work through them?

Does this person reliably answer the phone and respond to my messages?

*Make sure to write down your contacts' phone numbers down, and always have them available. Don't rely only on your phone to store numbers. You may find yourself in an area with poor reception, your phone may not be charged, or it might get broken during a crisis. It is very important to have a back-up plan.*

People who can help me resolve a crisis:

1. Name

2. Name _

Step 5: Professional resources I can use during a crisis.

If you need more support than your loved ones can provide, the next step is to contact a professional or agency for help. If you already have a doctor, counselor, social worker, or case manager, write them in below. If not, think about agencies you might be willing to contact for help. Ask for help locating resources in your area if you can't think of any.

c= Professionals or agencies I can contact during a crisis: I

Name

Name

VA Black Hills Health Care System:

Fort Meade campus (605) 347-2511 Hot Springs campus (605) 745-2000

VA Black Hills Health Care System Suicide Prevention:

Suicide Prevention Coordinator Office (605) 720-7087 Cell (605) 490-0098

* VETERANS CRISIS LINE: 1-800-273-8255 (TOLL FREE, 24/7)

Step 6: Strategies for helping me stay safe.

Identify several things that can help you maintain your safety. These might be strategies for avoiding a crisis, like avoiding alcohol or drugs. They also might be things you can do now to help avoid harming yourself or someone else if you have a crisis, like giving the gun cabinet keys to a friend or having someone keep your extra medications hidden.

Strategies for helping me stay safe: I

2.

Based on: Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version (Stanley & Brown, 2008).

Appendix C - VETERAN RECORD FLAG CATEGORY I HIGH RISK FOR SUICIDE

Veteran has been placed on the HIGH RISK FOR SUICIDE list, (Cat I Pt. Record Flag).

MEDICAL PROVIDERS: Be alert to Veteran making any threats of harm to self, seeking access to means to harm self, or talking/writing about death. Contact Veteran's Mental Health Provider, aetx t . the Suicide Prevention Team, at 490-0098 or 720-7087, or the Psychiatrist On Duty if you notice any of these signs.

ALL STAFF: Be respectful of Veteran's privacy. If the Veteran is exhibiting any of the warning signs for suicide, or if you have concerns, contact provider as above.

MENTAL HEALTH PROVIDER/case manager should initiate the following: Ensure Suicide Safety Plan has been completed. (Template under new note, "Suicide")

For the first 30 days after flag placement, suicide risk is to be evaluated WEEKLY.

(through )

After 30 days, suicide risk status needs to be evaluated at least monthly.

(through )

NO-SHOWS? Call 720-7087 or 490-0098 for potential welfare check and/or any case management needs.

Comment:

Appendix D - VETERAN HEALTH QUESTIONNAIRE 9 (PHQ9)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things:

0 Not at all 1 Several Days 2 More than half the days 3 Nearly every day

2. Feeling down, depressed or hopeless:

0 Not at all 1 Several days 2 More than half the days 3 Nearly every day

3. Trouble falling or staying asleep or sleeping too much:

1 Several days

4. Feeling tired or having little energy:

5. Poor appetite or overeating:

2 More than half days

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down:

3 Nearly everyday

7. Trouble concentrating on things, such as reading the newspaper or watching television:

8. Moving or speaking so slowly that other people could have noticed. Or the opposite

- being so fidgety or restless that you have been moving around a lot more than usual:

9. Thoughts that you would be better off dead, or of hurting yourself in some way:

Appendix E-SUICIDE BEHAVIOR REPORT

ZZTEST, ANYONE

123 ABC AVE

ANYTOWN STATE 00000

Home Phone: (999) 123-4567

SSN: 000-00-0000

DOB: JAN 1, 1945 (66)

Date!Time of event:

Location of event: On station Off station Veteran status at time of event: OutVeteran lnVeteran Outcome of event:

□ remained outpatient

□ died

□ hospitalized: indicate where in the box below

Source of information: Face-to-Face Telephone Written

□ Veteran self-report

□ Family member

□ Outside agent

□ VA Staff

□ Other:

Name & Phone # of source:

Time is approximate

Veterans stated: Level of INTENT of this event was: High Low (ASK: What did you think the outcome would be?)

Staff assessment: Level of INTENT of this event was: High Low Staff assessment: Level of LETHALITY of this event was: High Low

Last Pain Score: 0 (03/1712011 09:10)

Did the Veteran have access to firearms? Yes No Unknown

Family and other supports available at time of the event:

□ None

□ At least one supportive relationship

□ Some supportive relationships

□ Good social and/or family support

□ Other:

Treatment plan changes at the time of the event:

□ No changes □ Medication changes: describe: ------------

□ Therapy changes: describe: _ □Discharge from inVeteran/residential treatment within 30 days

□ Other:

Description of event:

Past 10 Clinic Visits:

03/10/2011 08:00 zzHS PC GREEN

03/08/2011 16:00 FM RESP CPAP

03/08/2011 14:00 FM RESP CPAP

03/04/2011 10:30 RC PC KOCH

03/03/2011 15:00 RC PC KOCH

02/14/2011 15:00 FM OPTOMETRY

CANCELLED BY VETERAN

CANCELLED BY CLINIC

CANCELLED BY CLINIC

CANCELLED BY CLINIC

Veteran has been receiving treatment in the following areas at the time of this event:

□ Mental Health

□ Substance Abuse

□ MHICM

□ PTSD

□ Life Skills Center

□ HBHC

□ Non-VA Mental Health Care

□ Ambulatory Care

□ CBOC

□ Specialty clinic: _

Primary Care Provider: _ Case Manager/Therapist: _ Name of Provider prescribing psychiatric medications:

Active Problem List:

Computerized Problem List is the source for the following:

1. Colonic Polyps ACTIVE 2/2011 tubular adenoma w/ low grade dysplasia. Repeat due in 2016

2. Encounter for Vocational Therapy (ICD-9-CM V57.22) ACTIVE

3. PTSD * (ICD-9-CM 309.81) ACTIVE

4. Cellulitis and abscess of upper arm and forearm ACTIVE

5. Screening for other specified conditions (ICD-9-CM ACTIVE

6. Chronic airway obstruction, Not Elsewhere Classifi ACTIVE elevated psa

7. CHF * (ICD-9-CM 428.0)

8. Hypertension

ACTIVE

9. Diabetes Mellitus without mention of Complication, ACTIVE

10. ASCVD

11. END STGE RENAL DIS

INACTIVE

(If Veteran was an inpatient at the time of event)

INVETERAN UNIT: _

Inpatient status at time of event:

□ On pass

□ Unauthorized Absence

□ On unit

□ Off unit

BRIEF PLAN/DISPOSITION:

□ None necessary -Veteran died

□ Limit the means

□ Developed crisis management plan

□ Immediate planning for the future

□ Decrease isolation

□ Decrease anxiety and agitation

□ Medication management

□ Hospitalization

□ Refer for Mental Health treatment

□ Provide emergency phone contact numbers

□ Assure follow-up appointment is made

□ Inform/involve someone close to Veteran

□ Increase contact frequency

□ Help Veteran through the crisis

□ Other - indicate below

**Please add the Suicide Prevention Coordinator and Risk Management Staff as an additional signer on this progress note.

Appendix F - SUICIDE RISK AND INTERVENTIONS

ISUICIDE RISK LEVELS

LOW RISK MODERATE RISK HIGH RISK

Suicidal ideation of limited Frequency, intensity and duration, no identifiable

Frequent suicidal ideation with limited intensity and duration, some specific

Frequent, intense and enduring suicidal ideation, specific plan with means plans, no intent, mild dysphoria/symptoms, good self-control, few risk plans, no intent, good self-control, limited dysphoria/symptoms, available and intent present, evidence of impaired self-control, factors, and identifiable some risk factors present, severe protective factors. Veteran identifiable protective dysphoria/symptoms, agrees to abstain from use factors, seeks help, multiple risk factors of drugs or alcohol, considers going to detox, seeks help or accepts accepts referral(s).

Participates In developing a "Safety Plan."

present without protective factors present. Ability to carry out safety plan in referral(s). question.

I INTERVENTIONS

LOW RISK

Evaluation of any

MODERATE RISK

Evaluation of need for

HIGH RISK

Immediate evaluation for expressed suicidal ideation to document behavioral higher level of care.

Increase in frequency of appropriate level of care as determined by Mental baseline of the Veteran for duration or outVeteran Health evaluation.

reassessment in the future. visits. Safety Plan completed, if

Active involvement of the not previously addressed.

family.

Reevaluation of treatment Means reduction as appropriate.

plan goals.

24 Hour availability of emergency or crisis services for Veteran.

Reevaluation of suicide risk.

Consideration of medication if symptoms worsen or persist.

Use of telephone/mail contacts for monitoring.

Input from family members.

Professional consultation as indicated.

Means reduced or removed from environment.

Reassess suicide risk per provider iudament.

Appendix G - SUICIDE RISK ASSEMENT

Current suicidal ideation: Yes No Plan: Yes No If yes, please explain:

Access to means: Yes No Intent: Yes No

Risk Factors:

S - Sex: FEMALE MALE A-Age: Age 15-24 or over 75: Yes No D - Depression: Yes No

P - Previous attempts: Yes No E - Ethanol/drug abuse: Yes No R - Rational thinking: Yes No S - Social support lacking: Yes No 0 - Organized plan: Yes No N - Spouse: Yes No S - Sickness: Yes No

Protective Factors:

Effective care for mental, physical and substance…