S02 ATTACHMENT D.37 - SOP 116A-06 MANAGEMENT_OF_HIGH_RISK_FOR_SUICIDE_PATIENT_RECORD_FLAGS.pdf

SOP 116A-06

MANAGEMENT OF HIGH RISK FOR SUICIDE PATIENT RECORD FLAGS

SOP 116A-06

Veterans Health Care System of the Ozarks (VHSO) Fayetteville, AR 72703

Signatory Authority:

Associate Chief of Staff, Mental Health

Responsible Owner:

Suicide Prevention Team

Service Line(s):

Mental Health

Effective Date:

March 10, 2023

Recertification Date:

March 10, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this Standard Operating Procedure (SOP) is to establish procedures on management of High Risk for Suicide Patient Record Flags (HRS-PRF).

This SOP must be followed by Suicide Prevention Teams and Mental Health Providers who manage and engage in care with Veterans with an HRS-PRF.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Memorandum 2022-02-02, Suicide Prevention Program Enhancements: High Risk for Suicide Patient Record Flag Referral Process and Updated Progress Notes;

VHA Directive 2010-053, Patient Record Flags, dated December 3, 2010; VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, dated July 1, 2008; VHA Memorandum 2020-01-11, Update to High Risk for Suicide Patient Record Flag Changes, dated January 16, 2020; VHA Notice 2020-13, Inactivation Process for Category I High Risk for Suicide Patient Record Flags, dated March 27, 2020; VHA Directive 1230 (1), Outpatient Scheduling Process and Procedures, dated July 15, 2016, VHA Memorandum 2017-06-30, Eliminating Veteran Suicide: Enhancing Acute Inpatient Mental Health and Residential Rehabilitation Treatment Program (RRTP) Discharge Planning and Follow-up, dated June 12, 2017;

and the Suicide Prevention Coordinator Guide, dated June 19, 2015.

2. PROCEDURES

a. HRS-PRF Placement.

(1) Activation determination.

(a) An e-consult is required when a patient:

1. Has been identified as high acute risk on a Comprehensive Suicide Risk Evaluation (CSRE).

2. Has a suicide attempt or suicidal preparatory behavior in the last 30 days.

March 10, 2023 SOP 116A-06

3. Has been admitted to mental health acute care due to suicidal ideation, with suicidal intent, and anyone who is not able to maintain safety without external support.

(b) Clinical Staff are required to complete Suicide Behavior and Overdose Report (SBOR) or CSRE for all suicidal behaviors within the past 12 months that have not been previously reported.

(c) The Suicide Prevention Team will review SBOR templates, including those completed in the CSRE, and Suicide Prevention (SP) Consults at least once each business day. The Suicide Prevention Team will determine which patients may require an HRS-PRF. SBORs, CSREs which report new suicidal behavior, and SP Consults placed after hours, weekends, or holidays will be reviewed by close of business the following business day.

1. HRS-PRF activation is required in the following situations:

a. In the last 30 days, a Veteran reports a suicide attempt or preparatory behaviors such as seeking access to lethal means; and/or

b. In the last 30 days, a clinician assessed the Veteran to have suicidal ideation with intent to die by suicide, resulting in admission to an inpatient psychiatry unit due to an inability to maintain safety independent of external supports.

(d) Once the determination for activation is made, the Suicide Prevention Team will place the HRS-PRF in VISTA and link to the Patient Record Flag Category I High Risk for Suicide progress note template in CPRS, including the clinical rationale for placement of the HRS-PRF.

(2) Patient notification. The Suicide Prevention Team or its designee will send written correspondence to the Veteran within 30 business days of the HRS-PRF placement, notifying the Veteran of the HRS-PRF placement, including contact information for the Privacy Officer.

b. HRS-PRF Enhanced Care.

(1) Case Management

(a) Case management will include ensuring the patient engages in safety planning, receives increased frequency of follow-up care, and receives follow-up for missed appointments for the duration of the HRS-PRF.

(b) The Suicide Prevention Team will monitor the provision of case management to all patients who have an HRS-PRF.

(2) Safety Plan

(a) Staff involved in the Veteran’s care will complete or update a safety plan on the Electric Health Record (EHR) within 7 days of HRS-PRF placement on the EHR. See

Appendix A for Department of Veterans Affairs (VA) Suicide Prevention Safety Plan and Suicide Behavior and Overdose Report (SBOR) Templates. Staff Specific Guidance.

(b) If the patient does not have a safety plan, the Suicide Prevention Team will notify the patient’s assigned team to request completion.

(3) Follow-up visits

(a) The patient’s assigned team will provide weekly, in-person or by telehealth, mental health follow-up visits to the patient for 30 days post HRS-PRF placement. See Appendix A.

1. Appointments should be scheduled in conjunction with Veteran preference. All four visits may be scheduled at one time, or the first visit may be scheduled with subsequent visits scheduled at the time of the last visit.

(b) The patient’s assigned team will provide a minimum of one, in-person or telehealth, mental health follow-up visits to the patient every 30 days thereafter, post HRS-PRF placement. Appointments should be scheduled in conjunction with Veteran preference.

(c) Assessment of suicidality, a review of current risk and protective factors, and a suicide risk mitigation plan, should occur and be documented in the EHR for all follow-up mental health visits for as long as the patient has an HRS-PRF.

(d) If the patient is admitted for inpatient or residential mental health care:

1. The patient’s assigned team will provide weekly, in-person or telehealth, mental health follow-up visits to the patient for 30 days post discharge.

2. All four visits may be scheduled at one time, or the first visit may be scheduled with subsequent visits scheduled at the time of the last visit.

3. Appointments should be scheduled in conjunction with Veteran preference.

4. If the patient leaves mental health inpatient or RRTP against medical advice or receives an irregular discharge, the patient’s assigned team and/or Suicide Prevention Team will contact the patient within 24 hours of discharge and will provide no less than two appointments, on separate days, within 7 days of leaving the facility.

(e) The patient may request follow-up visits by telephone or video telehealth in lieu of in person visits.

(f) If the patient no-shows to a mental health appointment:

1. the clinical staff with whom the patient was scheduled is required to make a total of four attempts to contact the patient to reschedule: three contact attempts by telephone on three consecutive business days, followed by a letter. The letter should be sent by the 3rd day of attempted contact and should include contact information for, at minimum, the clinical staff who sent the letter.

2. All attempted contacts must be documented in the EHR.

3. Contacts must be made by the patient’s provider or staff with a scope of practice that allows them to evaluate and triage high-risk behaviors.

(4) Financial Hardship.

(a) The patient’s assigned team will screen all high-risk patients for financial concerns and notify the Suicide Prevention Team if the Veteran has disclosed having outstanding debt to the VA.

(b) The patient’s assigned team will ensure the patient has been referred to the Facility Revenue Manager for assistance.

(c) The Facility Revenue Manager will assist the patient with applying for one of the hardship programs.

(5) Readjustment Counseling Services (RCS).

(a) Each month, the Suicide Prevention Team will send an encrypted e-mail to the Team Leader for each RCS location in the catchment area including a list of newly flagged patients and patients whose HRS-PRF has been removed.

(b) The Suicide Prevention Team will assist with care coordination, including between RCS staff and VHA staff.

c. HRS-PRF Transfer.

(1) Transfer timeframe. Once a patient has indicated desire to transfer to another VHA facility or an SPC determines a patient has moved to another catchment area:

(a) The Suicide Prevention Team will contact the Suicide Prevention Team in the new catchment area by encrypted e-mail within 1 business day, alerting the Suicide Prevention Team of the patient’s transfer/desire to transfer to the new area.

(b) If not already completed, the Suicide Prevention Team or designee will notify the facility Traveling Veteran Coordinator (TVC) of the patient’s transfer/desire to transfer within 1 business day.

(c) The TVC will enter a consult and/or notify the new facility TVC requesting transfer of care to the new facility within 1 business day.

(2) Mental health appointment at the new site.

(a) The Suicide Prevention Team or TVC will verify the patient has a mental health appointment at the new facility.

(b) If the patient does not have a scheduled mental health appointment, the Suicide Prevention Team or TVC will coordinate with the new facility and the patient to assist the patient with getting scheduled.

(3) Updated address in the EHR.

(a) The Suicide Prevention Team will verify the patient’s new address has been updated in the EHR.

(b) If the patient is homeless:

1. The Suicide Prevention Team will work with the patient to establish a potential temporary address in the new catchment area.

2. If a temporary address is established, the Suicide Prevention Team will notify administrative staff and request an update of the patient’s address in the EHR.

(4) Transfer of the HRS-PRF to the new site.

(a) Once all steps required for transfer have occurred, the Suicide Prevention Team will transfer the HRS-PRF to the new facility.

(b) If the patient does not or will not schedule an appointment with the new site, the HRS-PRF will not be transferred. The Suicide Prevention Team will continue to case manage the patient until the HRS-PRF has been inactivated or until a successful transfer occurs, whichever happens first.

d. HRS-PRF Review.

(1) Review timeframe. HRS-PRF reviews will occur within 10 days of the flag review by date.

(2) Consultation with treatment providers.

(a) The Suicide Prevention will notify treatment provider(s) they have a Veteran whose HRS-PRF is due for review no later than 3 days prior to the review date to:

1. request input regarding flag continuation or deactivation.

2. Notify the patient’s assigned team of the flag continuation because of recent suicidal behavior or recent admission with suicidal ideation and intent to die by suicide.

(b) By the due date, a review will occur between the patient’s assigned team and the Suicide Prevention Coordinator regarding:

1. feedback about the Veteran’s treatment engagement and progress since the HRS-PRF was initiated or since the last HRS-PRF review,

2. current level of acute suicide risk,

3. changes to risk and protective factors, and

4. recommendation to continue or inactivate the HRS-PRF.

(3) Additional consultation. If the Veteran has no assigned treatment providers or if the Suicide Prevention Team wishes additional consultation, the Suicide Prevention Team may request consultation from the VA Suicide Risk Management Consultation Program srmconsult@va.gov or the High-Risk Flag Advisory Committee.

(4) Clinical review. The Suicide Prevention Team will conduct a clinical review of the Veteran’s risk for suicide and rationale for HRS-PRF determination of continuance or inactivation. This review will include the following elements:

(a) Clinical engagement in care, in example:

1. Status and mitigation of acute risk factors identified at the time of HRS-PRF placement or continuance including:

a. Treatment engagement - appointments attended, noted no-shows or cancellations, review of medications and whether the patient has been filing them per the EHR, not just the patient’s verbalized report, participation in recommended therapies and use of supportive networks.

b. Management of psychosocial stressors - improvement, exacerbation, or resolution, notation of resiliency or problem-solving capacity, or increase in social supports; and

c. Safety planning – access to lethal means, willingness to use safety planning steps.

2. Status of severity, frequency, and intensity of suicidal ideation

3. Recent SDV behaviors, suicidal and non-suicidal, including preparatory

4. Recent hospitalizations, especially for psychiatric symptoms, chronic illness, or newly diagnosed terminal conditions

5. Active substance use

6. Engagement in help seeking behaviors - contacts with the Veterans Crisis Line, new requests for additional mental health treatment modalities, requests for modification of medications to manage symptoms

7. Current assessment of acute and chronic risk.

(b) Clinical consultation on the advisability of inactivating or continuing the HRS- PRF. (Note: Additional consultation options may include VA Suicide Risk Management Consultation Program srmconsult@va.gov or High-Risk Flag Advisory Committee) mailto:srmconsult@va.gov mailto:srmconsult@va.gov

(c) Attempted outreach for engagement including a review of all attempts to outreach to the patient after no shows and cancelled appointments

(5) HRS-PRF review documentation. The Suicide Prevention Team will document the HRS-PRF review, to include the determination to inactivate or continue the HRS- PRF and update the HRS-PRF in the EHR no later than 1 business day after such determination.

(6) If the HRS-PRF has been inactivated, the Suicide Prevention Team or designee will notify the patient of this decision via U.S. Mail. The Suicide Prevention Team or designee will include contact information for the Veterans Health Care of the Ozarks VAMC Suicide Prevention Team, the Veterans Crisis Line, and relevant local community resources.

e. Caring Communications.

(1) As part of enhanced care for patients once their HRS-PRF has been removed, the Suicide Prevention Team will add the patient to the Veterans Health Care System of the Ozarks Caring Communication list. The Suicide Prevention Team or designee will send caring content correspondence via U.S. Mail to the patient every month for 12 consecutive months.

(2) If the patient requests to be removed from receiving Caring Communications, The Suicide Prevention Team or designee will document this request in the EHR and cease sending caring communication content.

(3) If the patient is homeless, the Suicide Prevention Team or designee should attempt to send Caring Communications through a temporary address if possible. If there is no temporary address, the Suicide Prevention Team or designee will consider whether other means of caring communication are appropriate such as texting, e-mail, telephone, or MyHealth e-Vet contacts. The Suicide Prevention Team or designee will ensure all methods of electronic communication have been reviewed and approved by the facility Privacy Officer.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Veterans Health Care System of the Ozarks Mental Health Care Line Executive. In accordance with the responsibility in VHA Notice 2020-13 and VHA Directive 2008-036, that the VA medical facility Director must ensure Veterans Health Care System of the Ozarks has an SOP outlining facility management of HRS-PRFs, this SOP assigns the responsibility to the Veterans Health Care System of the Ozarks Associate Chief of Staff of Mental Health to ensure facility staff comply with requirements of this SOP and ensuring this SOP is updated at least every 2 years.

b. Veterans Health Care System of the Ozarks Suicide Prevention Coordinator(s). The Veterans Health Care System of the Ozarks Suicide Prevention Coordinator(s), or other SP Team designee, are responsible for accepting referrals for and managing patients who have an HRS-PRF in accordance with procedures in this SOP and requirements in the VHA Directives, Notices, Handbooks, and Memorandums.

c. Veterans Health Care System of the Ozarks Mental Health Providers. All Veterans Health Care System of the Ozarks mental health providers are responsible for referring to and consulting with the Veterans Health Care System of the Ozarks SP Team about patients who may be eligible for or who have an HRS-PRF and for providing care to those patients in accordance with procedures in this SOP and requirements in the VHA Directives, Notices, Handbooks, and Memorandums.

4. REFERENCES

a. 116A-02 SOP, Screening and Management of the Suicidal Homicidal Patient, dated September 28, 2020.

b. VHA Memorandum 2022-02-02, Suicide Prevention Program Enhancements:

High Risk for Suicide Patient Record Flag Referral Process and Updated Progress Notes, dated February 2, 2022.

c. VHA Directive 2010-053, Patient Record Flags, dated December 3, 2010.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341.

d. VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, dated July 1, 2008.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1719.

e. VHA Notice 2020-13, Inactivation Process for Category I High Risk for Suicide Patient Record Flags, dated March 27, 2020.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8773.

f. VHA Memorandum 2020-01-11, Update to High Risk for Suicide Patient Record Flag Changes, dated January 16, 2020.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8671.

g. VHA Directive 1605.01, Privacy and Release of Information, dated August 31, 2016. https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233.

h. VHA Directive 1230 (1), Outpatient Scheduling Process and Procedures, dated July 15, 2016. https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3218.

i. VHA Handbook 1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics, dated September 9, 2008, Amended November 16, 2015.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762.

j. VHA Handbook 1907.01 Health Information Management and Health Records, dated March 19, 2015.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088.

https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2F116A%2D02%20SOP%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2F116A%2D02%20SOP%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9647 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9647 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9647 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1719 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8773 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8671 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3218 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3088

k. VHA Handbook 1101.11(3), Coordinated Care for Traveling Veterans, dated April 22, 2015. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099.

l. VHA Memorandum 2018-06-18, Suicide Prevention Safety Plan National CPRS Note Templates Implementation, dated June 1, 2018.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8237.

m. VHA Memorandum 2019-04-06 Suicide Behavior and Overdose Report Computerized Patient Record System (CPRS) Note Template Implementation, dated April 8, 2019. https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8314.

n. VHA Directive 1162.02, Mental Health Residential Rehabilitation Treatment Program, dated July 15, 2019 VHA Directive 1162.02 Mental Health Residential Rehabilitation Treatment Program.

o. VHA Memorandum 2008-04-04 Patient at High-Risk for Suicide, dated April 24, 2008. https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8687.

p. VHA Memorandum 2018-06-18 Suicide Prevention Safety Plan National CPRS Note Templates Implementation, dated June 1, 2018.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8237.

q. VHA Memorandum 2018-11-12, Memorandum of Understanding between Office of Mental Health and Suicide Prevention and Readjustment Counseling Services, dated November 13, 2017.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8231.

r. VHA Memorandum 2018-08-08, Memorandum of Understanding between VHA’s Office of Mental Health and Suicide Prevention and Office of Community Revenue Operations, Consolidated Patient Account Center Facility Revenue Offices, dated August 2018, Suicide Prevention Coordinator SharePoint Site. NOTE: This is an internal VA Web site that is not available to the public.

s. Suicide Prevention Coordinator Guide dated November 1, 2020. Suicide Prevention Coordinator SharePoint Site. NOTE: This is an internal VA Web site that is not available to the public.

5. RECORDS REVIEW

All records will be maintained and inventoried in accordance with Medical Center Memorandum (MCM) 04-03 and Records Control Schedule (RCS) 10-1. Records will be inventoried on the Mental Health record file and inventory plan.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3099 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8237 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8314 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Fvhapublications%2FViewPublication.asp%3Fpub_ID%3D8400&data=04%7C01%7C%7C2066c55c60c242be8d2208da0c1385dd%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637835575240071158%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=Cxd4EMDf5qiQeGY%2F7MjF0pefSacPKBCWZ966D6%2B6AQs%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.va.gov%2Fvhapublications%2FViewPublication.asp%3Fpub_ID%3D8400&data=04%7C01%7C%7C2066c55c60c242be8d2208da0c1385dd%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637835575240071158%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=Cxd4EMDf5qiQeGY%2F7MjF0pefSacPKBCWZ966D6%2B6AQs%3D&reserved=0 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8687 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8237 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8231 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Forms/AllItems.aspx?id=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding%2F2018%2E08%20%2D%20MOU%20Between%20VA%20OMHSP%20and%20Office%20of%20Community%20Revenue%20Operations%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding&p=true&wdLOR=c045754AD%2D1255%2D49A9%2DB1C9%2D4BDC84A21776 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Forms/AllItems.aspx?id=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding%2F2018%2E08%20%2D%20MOU%20Between%20VA%20OMHSP%20and%20Office%20of%20Community%20Revenue%20Operations%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding&p=true&wdLOR=c045754AD%2D1255%2D49A9%2DB1C9%2D4BDC84A21776 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Forms/AllItems.aspx?id=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding%2F2018%2E08%20%2D%20MOU%20Between%20VA%20OMHSP%20and%20Office%20of%20Community%20Revenue%20Operations%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding&p=true&wdLOR=c045754AD%2D1255%2D49A9%2DB1C9%2D4BDC84A21776 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Forms/AllItems.aspx?id=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding%2F2018%2E08%20%2D%20MOU%20Between%20VA%20OMHSP%20and%20Office%20of%20Community%20Revenue%20Operations%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2Fvisn2coe%5Fsp%2Fsp%2FMemos%20Directives%20and%20Admin%20Items%2FMemos%2FMemorandums%20of%20Understanding&p=true&wdLOR=c045754AD%2D1255%2D49A9%2DB1C9%2D4BDC84A21776 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Suicide%20Prevention%20Program%20Guide/Suicide%20Prevention%20Program%20Guide%20-%20November%202020%20-%20508.pdf?OR=Teams-HL&CT=1648240984796&params=eyJBcHBOYW1lIjoiVGVhbXMtRGVza3RvcCIsIkFwcFZlcnNpb24iOiIyNy8yMjAzMDcwMTYxMCJ9 https://dvagov.sharepoint.com/sites/VACOMentalHealth/visn2coe_sp/sp/Memos%20Directives%20and%20Admin%20Items/Suicide%20Prevention%20Program%20Guide/Suicide%20Prevention%20Program%20Guide%20-%20November%202020%20-%20508.pdf?OR=Teams-HL&CT=1648240984796&params=eyJBcHBOYW1lIjoiVGVhbXMtRGVza3RvcCIsIkFwcFZlcnNpb24iOiIyNy8yMjAzMDcwMTYxMCJ9

6. REVIEW

This SOP must be reviewed, at a minimum, at recertification, when there are changes to any of the governing documents, and any regulatory requirement for more frequent review. VHSO Suicide Prevention Team will submit proposed modifications to this SOP to the VHSO Mental Health Care Line Executive a minimum of 1 month prior to recertification.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of March 2028. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Reba Glidewell, PhD, LP Associate Chief of Staff, Mental Health Service

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Via Intranet

ATTACHMENTS: A

SOP 116A-06

Attachment A

Department of Veterans Affairs (VA) Suicide Prevention Safety Plan and Suicide Behavior and Overdose Report (SBOR) Templates

Staff Specific Guidance

A Suicide Prevention Safety Plan is a brief clinical intervention, collaboratively developed between a Veteran and a provider, for use during or before a suicidal crisis.

The following criteria regarding which VHA staff members can develop a safety plan with a patient go into effect 09/30/19. In the interim, staff who currently develop safety plans with their patients can continue to do so.

VHA staff members can develop a safety plan with a patient if:

1. There is a “Yes” next to the staff member’s credentials in the table below; AND

2. The local facility Chief of Staff concurs with this determination; AND

3. The staff member has documented training via the TMS course (VA-36232 Suicide Safety Plan Training Recording); AND

4. Safety planning is within written scope of practice and/or competency per local policy.

5. Suicide Behavior and Overdose Reports (SBOR) collects information on suicidal behaviors and overdoses. A VHA staff member can complete an SBORs if it is within local staff scope of practice and there is a “Yes” next to the staff member’s credentials in the table on the next page.

1Medical Doctor/Doctor of Osteopathic Medicine; 2Doctor of Philosophy/Doctor of Psychology; 3Licensed Clinical Social Worker/Licensed Master of Social Work/Licensed Independent Social Worker; 4Licensed Marriage and Family Therapist;

5Licensed Professional Mental Health Counselor; 6Licensed Practical Nurse; 7Registered Nurse; 8Advanced Practice Registered Nurse: Nurse Practitioner/Clinical Nurse Specialist; 9Physician’s Assistant; 10Unlicensed Assistive Personnel, including Health Tech, Medical Assistant, and Nursing Assistant.

Note: A trainee in ANY of these categories may complete each step marked with a “Yes” with an appropriate co- signer https://vaww.cmopnational.va.gov/CR/MentalHealth/Suicide%20Prevention/Safety%20Planning/TMS%20Suicide%20Safety%20Planning%20recording.pdf https://vaww.cmopnational.va.gov/CR/MentalHealth/Suicide%20Prevention/Safety%20Planning/TMS%20Suicide%20Safety%20Planning%20recording.pdf https://vaww.cmopnational.va.gov/CR/MentalHealth/Suicide%20Prevention/Safety%20Planning/TMS%20Suicide%20Safety%20Planning%20recording.pdf