S02 ATTACHMENT D.31 - SUICIDE_RISK_SCREENING_AND_EVALUATION.pdf
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- Q201--Harrison, AR Community Based Outpatient Center (CBOC) Federal contract opportunity
- Solicitation number
- 36C25623R0079
About this file
This document outlines standard operating procedures for suicide risk screening and evaluation at a Veterans Health Care System facility. It details requirements for annual universal screening using the Columbia Suicide Severity Rating Scale and follow-up comprehensive suicide risk evaluations as needed. It assigns responsibilities to various roles and defines key terms. Screening is required for all veterans annually and additionally as clinical situations indicate. Comprehensive evaluations must be completed same day by a licensed independent provider for any veterans screening positively. The procedures are in compliance with VA memorandums on suicide risk screening and evaluation requirements.
The related federal contract opportunity solicitation requests services for a new Community Based Outpatient Clinic in Harrison, Arkansas to provide both primary care and mental health support services including pharmacy, laboratory, and x-ray. The contractor must provide a facility within city limits as well as mental health registered nurse support staff and space for VA mental health providers, but will not be responsible for direct provision of mental health services. The period of performance and pricing terms are not specified. The soliciting agency is the Department of Veterans Affairs Veterans Health Administration VISN 16.
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SUICIDE RISK SCREENING AND EVALUATION
SOP [NUMBER]
Veterans Health Care System of the Ozarks (VHSO) Fayetteville, AR 72703
Signatory Authority:
Associate Chief of Staff Mental Health
Responsible Owner:
Suicide Prevention Supervisor
Service Line(s):
All Ambulatory Areas
Effective Date:
February 1, 2023
Recertification Date:
February 1, 2028
1. PURPOSE AND AUTHORITY
a. The purpose of this standard operating procedure (SOP) is to establish procedures on the Department of Veterans Affairs (VA) Suicide Risk Screening and Evaluation Requirements. This SOP must be followed by all staff identified on the Department of Veterans Affairs Suicide Risk Identification Strategy: Staff Specific Guidance and the Department of Veterans Affairs (VA) Suicide Prevention Safety Plan and Suicide Behavior and Overdose Templates: Staff Specific Guidance.
b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Memorandum: Suicide Risk Screening and Evaluation Requirements and Implementation Update (Risk ID Strategy) November 23, 2022.
2. PROCEDURES
a. The Universal Screening requirement dictates all Veterans will be screened annually with the Columbia Suicide Severity Rating Scale (C-SSRS). If positive on this screening, a Comprehensive Suicide Risk Evaluation (CSRE) will be completed the same day by a Licensed Independent Provider (LIP).
b. Annual suicide risk screening will be facilitated through the clinical reminder system. The annual suicide risk screen reminder will be satisfied by appropriate staff, at a Veteran’s encounter, when it is due. This reminder will be satisfied regardless of other setting-specific requirements for suicide risk screening and/or evaluation. All service areas are expected to complete the annual suicide risk screen when due.
(1) If the Veteran is too ill or unable to participate or declines screening, staff will select that option and document relevant clinical information in the comment box. The clinical reminder will be resolved for one day and will be due again the next calendar year.
(2) An option of “unable to screen” may occur due to the following reasons: The Veteran is diagnosed with dementia, ICD-10-CM codes: A8100, A8101, A8109, A812, A8182, A8189, A819, F0150, F0151, F0280, F0281, F0390, F0391, F1027, F1097, February 1, 2023 SOP [NUMBER]
F1327, F1397, F1817, F1827, F1897, F1917, F9127, F1997, G231, G300, G301, G308, G309, G3101, G3109, G3183, or G903. The clinical reminder will be met for 1 year.
(3) The Veteran is diagnosed with severe chronic cognitive impairment, to be documented in the encounter using the Clinical Dementia Rating Scale (CDR) with a score of not less than 2 or using the Functional Assessment Staging Tool (FAST) with a score of not less than 5, or the Global Deterioration Scale (GDS) with a score not less than 5. The clinical reminder will be met for 1 year.
(4) The Veteran has a life expectancy of less than 6 months, for terminal cancer patients and is coded as such. The clinical reminder is fully met.
c. A positive C-SSRS (positive answers to items 3, 4, 5, 8), requires the timely completion of the CSRE.
(1) If the positive C-SSRS is not completed by a LIP, a warm hand-off will be provided to one for completion of the CSRE.
d. In addition to annual universal screening, all other setting-specific screening and evaluation requirements which should be followed.
e. The Universal and Setting specific requirements provide a general approach for completion of the suicide risk screening and evaluation protocols. There may be additional clinical situations such as when a Veteran presents with new mental health concerns, where use of the C-SSRS screener and/or CSRE is indicated.
f. At any Veteran encounter, to include suicide screening and evaluation, appropriate staff are required to complete Suicide Behavior and Overdose Reports (SBOR) (either in the standalone template or within the CSRE) for all suicidal behaviors, to include preparatory behavior, within the past 12 months.
(1) Following the Suicide Prevention Team’s review of suicidal behavior in an SBOR or CSRE, Quality, Safety and Value and Mental Health Leadership will be made aware of any suicidal behavior which occurred in the last year. Joint Patient Safety Reporting, Issue Briefs, and Root Cause Analyses will be completed as required by local and national policy.
3. ASSIGNMENT OF RESPONSIBILITIES
a. Medical Center Director. The Medical Center Director is responsible for the development of Medical Center policies and procedures related to the prevention and management of Veterans with suicidal behavior or increased suicide risk.
b. Chief of Staff. The Chief of Staff is responsible for implementing Medical Center policy; reporting to the Director unusual incidents in the management of Veteran care;
and arranging a quality improvement review of suicide attempts or deaths, when indicated.
c. Chiefs of All Service Lines. are assigned the responsibility to ensure staff awareness and adherence to the Suicide Risk Identification Process within their Services.
d. All Medical Center Personnel. are assigned the responsibility for identification, reporting, and documentation of potential suicide risk to ensure immediate safety of the Veteran. Clinical decisions related to the management of Veteran’s at risk for suicide are the responsibility of the Veteran’s treatment team as directed by their primary care, attending, or mental health provider.
e. Licensed Independent Practitioner (LIP) and clinical staff. All LIP and clinical staff are responsible for evaluating and responding to potential suicide risk in accordance with the VHA Suicide Risk Screening and Assessment Requirements.
f. Suicide Prevention Team. The Suicide Prevention team is made up of LIPs with administrative responsibilities to include assigning high risk for suicide flags; supporting staff in their treatment and management of at-risk Veterans within facility; coordinating strategies to increase the awareness and adoption of suicide prevention best practices;
and fulfilling key outreach and training responsibilities as part of VA’s public health model. Suicide Prevention Coordinators (SPCs) serve as subject matter experts for all matters relating to preventing Veteran suicide. The SPCs are not crisis workers.
g. Quality, Safety and Value. Quality, Safety and Value is responsible for working closely with the Suicide Prevention staff for tracking and trending all of suicide attempts and deaths; providing data to service and medical center management; and monitoring adherence to VA policy documentation for Suicide Prevention.
4. DEFINITIONS
a. Clinical Staff. Any individual with similar parameters as a Licensed Independent Provider (LIP) but has not been credentialed as a LIP. The clinical staff provide clinical treatment to a Veteran.
b. Columbia Suicide Severity Rating Scale (C-SSRS). The screen adapted from the full version of the C-SSRS that consists of 3-8 questions that specifically query about the severity of suicidal ideations and suicidal behavior, such as a wish to die, suicidal thoughts without intent, suicidal thoughts with specific plan and intent, and recent preparatory behavior of suicide attempt.
c. Comprehensive Suicide Risk Evaluation (CSRE). The second stage in the screening process which is an evidence-based evaluation used to determine acute and chronic suicide risk and develop a risk management plan to meet the individual needs of the Veteran at suicide risk.
d. Clinical Dementia Rating (CDR) Scale. 5-point scale used to characterize six domains of cognitive and functional performance (memory, orientation, judgement, and problem solving, community affairs, home and hobbies, personal care).
e. Functional Assessment and Staging Tool (FAST. Charts decline of patients with Alzheimer’s Disease and is broken down into 7 stages. Score indicates moderate to severe.
f. Global Deterioration Scale (GDS). Provides an overview of the stages of cognitive impairment and is broken down into 7 stages. Score indicates moderate-severe.
g. Licensed Independent Provider (LIP). Any individual permitted by law and by facility to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted privileges.
h. Self-directed Violence. Behavior that is self-directed and deliberately results in injury or potential injury to oneself.
i. Preparatory behavior. Acts or preparation towards engaging in self-directed violence, but before potential for injury has begun. This includes anything beyond a verbalization or thought, such as assembling a method or preparing for one’s death by suicide.
j. Suicide. Death caused by self-inflicted, injurious behavior with intent to die because of the behavior.
k. Suicide attempt. A non-fatal, self-inflicted, potentially injurious behavior with intent to die because of the behavior.
l. Suicidal ideation. Thoughts of engaging in suicide-related behavior.
m. Suicidal intent. There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill themself, and understand the probable consequences of their actions or potential actions. Suicide intent can be determined retrospectively and in the absence of suicidal behavior.
n. Warm hand-off. The Action of physically, and/or verbally if by phone, remaining with the Veteran until the staff can connect the Veteran with another person. If in the context of a positive C-SSRS, staff member would remain with Veteran until the Veteran is with another staff for the CSRE.
5. REFERENCES
a. Department of Veterans Affairs (VA) Suicide Risk Identification Strategy: Minimum Requirements by Setting (Version November 4, 2021) Suicide Risk Identification Strategy.
b. VHSO SOP 118-16: Hand Off Communication dated March 30, 2022.
c. Department of Veterans Affairs (VA) Suicide Risk Identification Strategy: Staff Specific Guidance (Version December 23, 2022).
https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?FolderCTID=0x012000E86563DBD1AE964BB1325C495848890F&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance%2FSuicide%20Screen%20Requirements%20by%20Setting%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?FolderCTID=0x012000E86563DBD1AE964BB1325C495848890F&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance%2FSuicide%20Screen%20Requirements%20by%20Setting%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?FolderCTID=0x012000E86563DBD1AE964BB1325C495848890F&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance%2FSuicide%20Screen%20Requirements%20by%20Setting%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FSetting%20Specific%20Guidance https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FSOP%20118%2D16%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs&OR=Teams%2DHL&CT=1672433515795&clickparams=eyJBcHBOYW1lIjoiVGVhbXMtRGVza3RvcCIsIkFwcFZlcnNpb24iOiIyNy8yMjExMzAwNDEwMCIsIkhhc0ZlZGVyYXRlZFVzZXIiOmZhbHNlfQ%3D%3D https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance%2FRisk%20ID%5FStaff%20Specific%20Guidance%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance%2FRisk%20ID%5FStaff%20Specific%20Guidance%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance
d. Department of Veterans Affairs (VA) Suicide Prevention Safety Plan and Suicide Behavior and Overdose Templates: Staff Specific Guidance (Version April 17, 2019).
e. Department of Veterans Affairs (VA) Suicide Risk Identification Strategy, Frequently Asked Questions (FAQ) January 5, 2023.
f. VHA Memorandum: Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation Update (Risk ID Strategy). November 23, 2022.
g. VA’s Self-Directed Violence Classification System.
6. REVIEW
Required review will occur at minimum at recertification when there are changes to the national policy or when health care accreditation body mandate is issued.
7. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of February 2028. In the event of contradiction with national policy, the national policy supersedes and controls.
8. SIGNATORY AUTHORITY
Reba Glidewell, PhD, LP ACOS, Mental Health Service Date Approved: Month Day, Year
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
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| 3. ASSIGNMENT OF RESPONSIBILITIES |
| 4. DEFINITIONS |
| 5. REFERENCES |
| 6. REVIEW |
| 7. RECERTIFICATION |
| 8. SIGNATORY AUTHORITY |
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