S02 Attachment Seventeen 17 Medical Care Memorandum Number 548 116 173 Identification and Management of Veterans.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER 548-116-173

WEST PALM BEACH, FLORIDA December 4,2019

IDENTIFICATION AND MANAGEMENT OF VETERANS

AT RISK FOR SELF-DIRECTED VIOLENCE AND SUICIDE

PURPOSE:

To establish policy and procedures for the identification, assessment, and management of risk for self-directed violence and suicide among Veterans receiving care in the West Palm Beach Medical Center and Community Based Outpatient Clinics. This local policy has been developed in accordance with the VA Suicide Risk Identification Strategy Directive dated May 23, 2018, modified November 2, 2018 and includes The Joint Commission (TJC) National Patient Safety Goal that went into effect July, 1, 2019.

I. Table of Content

II. Policies & Procedures -- Table Of Contents: Page

A. Suicide Risk Screening & Evaluation Process and Safety Planning

B. Qualified Providers 4

C. SETTING SPECIFIC: Suicide Risk Screening & Evaluation Process and Safety Planning

1. Emergency Department 7

2. PACT 9

3. HBPC 10

4. Acute Medicine/Surgery Inpatient Wards 11

5. Outpatient Mental Health Programs/Clinics 12

6. MH RRTP/ General Domiciliary 14

7. Inpatient Psychiatric Ward 17

8. CLC 18

9. Pain Clinic 19

10. Sleep Clinic 19

11. CBOCs 19

12. PCT 20

Attachment Seventeen (17) - Medical Care Memorandum Number 548-116-173 -

Identification and Management of Veterans 36C24821R0092

D. Other 21

ATTACHMENTS/APPENDICES

A. Primary Suicide Screen 25

B. Columbia Suicide Severity Rating Scale (C-SSRS) 26

C. Comprehensive Suicide Risk Evaluation (CSRE) 27

D. Safety Plan 31

E. Risk Stratification Table 34

F. Baker Act Procedures 36

G. Managing a Crisis Call 37

H. Managing Situations on Premises 40

I. Management of Suicidal Patients in Non-Mental Health Inpatient Wards and All Ambulatory Settings

J. Management of Suicidal Patients in Psychiatric Ward

K. No Show Procedures 44

L. Health & Welfare Procedures 45

M. Reporting Suicide Behaviors and Overdose 46

N. Medication Restrictions 48

O. Self-Directed Violence Classification System 49

P. Definitions 51

Q. Nexus Clinics 55

R. Workflow for Clinical Reminders in Ambulatory Settings

III. POLICY & PROCEDURES:

The Veterans Health Administration is committed to preserving life and maintaining the physical and psychological integrity of Veterans. In order to accomplish these goals, it is necessary to identify those Veterans at increased risk for self-directed violence and suicidal behaviors and to treat them intensively. The facility must appropriately and effectively assess, identify, and provide enhanced treatment options for Veterans at heightened risk for self-directed violence and suicide. Treatment for at-risk Veterans must be modified as deemed clinically appropriate given their location and risk status.

Suicide prevention is the responsibility of every Medical Center employee. Therefore, each Medical Center employee is responsible for being alert to potential signs and symptoms of suicide/self-directed violence, identifying at-risk patients, and reporting troubling patient statements and behaviors to professional clinicians responsible for direct patient care. The Operation S.A.V.E. Suicide Prevention Training is mandatory for all VA staff during new employee orientation (within the first 90 days of employment and annually thereafter), as this training provides knowledge and procedural guidelines for assisting suicidal Veterans and helping them to obtain treatment. All clinical staff members are required to participate in suicide prevention training regarding suicide risk management and protocols. Specific training will also be provided to staff based on need, request, and procedural changes.

All VAMC employees play an important role in reducing suicide risk.

All employees are responsible for: (1) Recognizing signs and symptoms of suicidal ideation; (2) Asking appropriate questions related to suicidal ideation when signs/symptoms are identified;

(3) Validating Veteran’s experience; and (4) Ensure referral for assessment and/or emergent assistance when patients are at imminent risk for suicide.

A. Suicide Risk Screening & Evaluation Process and Safety Planning:

Depending upon the setting a suicide risk screening and evaluation must be completed by qualified providers define in section II B.

The Three Stage Process is as follows:

When the Primary Screen is positive (PHQ-9, Item 9), identifies those who may be at risk, the Secondary Screen (C-SSRS) must be completed. When the Secondary Screen (C-SSRS), which improves the specificity of screening, is positive a Comprehensive Suicide Risk Evaluation (CSRE) is required using the progress note title Suicide Risk Evaluation – Comprehensive (CSRE 2.0). The CSRE provides clinical impression about acute and chronic risk associated with disposition. See setting specific section for further details regarding the Suicide Risk Screeing, Evaluation and Safety

Primary Screen PHQ-9 Item #9

Secondary Screen (C-SSRS) Columbia – Suicide

Severity Rating Scale

Comprehensive Suicide Risk Evaluation (CSRE)

Planning process. See Appendix A for the Primary Screen, Appendix B for the Secondary Screen and Appendix C for the Comprehensive Suicide Risk Evaluation.

B. Qualified Provider:

A physician, psychiatrist, psychologist, mid-level provider, social worker, physician assistant, registered nurse, (or trainee with appropriate co-signature) or other allied healthcare professional, who by virtue of educational background and approved credentialing, privileging and/or scope of practice has been determined by the facility. Discipline specific role for Primary, Secondary Screen and CSRE included below:

Primary Screen*

Secondary Screen**

CSRE

MD/DO

Yes Yes Yes

Licensed Psychologist (PhD/PsyD) Yes Yes Yes

Clinical Pharmacy Specialist Yes Yes Yes

LCSW/LMSW/LISW

Yes Yes Yes

LMFT

Yes Yes Yes

LPMHC

Yes Yes Yes

Addiction Therapist Yes Yes No

LPN

Yes No No

RN

Yes Yes

No

APRN: NP/CNS

Yes Yes Yes

PA

Yes Yes Yes

Peer Support Specialist Yes No No

UAP

Yes No No

RT and MIT No No No

PT/OT/KT Yes No No

Vocational Rehabilitation Specialist Yes No No

Rehabilitation Counselor Yes Yes No

*Primary Screen: The Patient Health Questionnaire -9 (PHQ-9) Item #9

**Secondary Screen: The Columbia Suicide Severity Ration Scale (C-SSRS)Screener.

+RN’s can administer the secondary screen via Mental Health Assistant or using the progress note template for the Columbia, but they cannot administer the secondary screen via the Clinical Reminder System because it contains disposition.

++Rehabilitation Counselors can administer the secondary screen via Mental Health Assistant or the separate progress note template for the Columbia, or when licensed and included in local bylaws as an independent practitioner, via the Clinical Reminder System.

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 Roistered Nurse; Nurse Practitioner/Clinical Nurse Specialist; 9Physician Assistant, 10Unlicensed Assistive Personnel, including Health Tech, Medical Assistant, and Nursing Assistant, 11Respiratory Therapist and Medical Instrument Technologists, 12Physical Therapist, Occupational Therapist, Kinesiotherapist.

Note: A trainee in ANY of these categories may complete each step marked with a “Yes” with an appropriate co-signer.

Suicide Behavior and Overdose Report (SBOR) and Safety Planning are included in the chart below:

SBOR SP Safety Plan MD/DO1 Yes Yes Licensed Psychologist (PhD/PsyD)2 Yes Yes Clinical Pharmacy Specialist Yes Yes LCSW/LMSW/LISW3 Yes Yes LMFT4 Yes Yes LPMHC5 Yes Yes Addiction Therapist Yes Yes LPN6 No No RN7 Yes Yes APRN: NP/CNS8 Yes Yes PA9 Yes Yes Peer Support Specialist No No UAP10 No No Psychological Technician, Social Work Assistant

No No

Vocational Rehabilitation Specialist No No Rehabilitation Counselor Yes Yes

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.

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 below.

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

C. SETTING SPECIFIC Suicide Risk Screening & Evaluation Process and Safety Planning:

Setting

Screening and/or Evaluation Requirements

Primary Screen (I9)

Secondary Screen (C-SSRS) based upon Positive Primary Screen or Program Requirement

Comprehensive Evaluation (CSRE) based upon Positive Secondary Screen or Program Requirement

Emergency Department and Urgent Carea++

The primary and secondary screens are both a part of the National Emergency Department Triage note

Primary Care and other NEXUS Clinicsb; PCMHI

Annually in conjunction with required depression and PTSD screening

PHQ-2 + I9*

PC PTSD-5 + I9*

Outpatient Mental Healthc

During intake evaluation

As clinically indicated

Inpatient Mental Health

C-SSRS (and CSRE if indicated) within 24 hours of admission and within 24 hours before discharge

Mental Health Residential Rehabilitation Treatment Program***

Screening with C-SSRS (and CSRE if indicated) within 24 hours of admission and CSRE during the first week of admission; updated CSRE within a week before discharge and C-SSRS (and updated CSRE if indicated) within 24 hours before discharge***

Opioid Therapy Program

Screening with C-SSRS (and CSRE if indicated) within 24 hours of admission and CSRE at some point during the stay; updated CSRE within 24 hours before discharge

Sleep Clinic I9 at referral or intake (and

C-SSRS/CSRE if indicated); I9 completed during intake evaluation if > 30 days from referral

I9*

Pain Clinic I9 at referral or intake (and C-SSRS/CSRE if indicated); I9 completed during intake evaluation if > 30 days from referral

Inpatient Medical/Surgical**

I9 (and C-SSRS/CSRE if indicated) within 24 hours of admission and within 24 hours before discharge to home

Inpatient Rehabilitation**

I9 (and C-SSRS/CSRE if indicated) within 24 hours of admission and within 24

Community Living Center**

I9 (and C-SSRS/CSRE if indicated) within 24 hours of admission and within 24

1.) Emergency Department (ED)

All patients treated in the ED must have a Suicide Risk Screening and Evaluation following a two-step process effective November 18, 2019 the Primary Screen was eliminated. The primary and secondary screens are both a part of the National Emergency Department Triage Note. The qualified provider/staff must complete a Secondary Screen, CSSRS. CSRE is to be completed on the same day as a positive secondary screen unless it is not logistically feasible or clinically appropriate for the ED. In those cases it is acceptable to complete the CSRE within 24 hours.

The primary and secondary screening is to be completed by a qualified provider (see Section II B) and if positive, the registered nurse should immediately notify the physician who will enter a Mental Health Consult for C&L Psychiatry and an order for 1:1 observation.

All Veterans evaluated in the ED with a chief complaint that is a psychiatric problem and deemed at no imminent risk or Veterans who are determined to be at INTERMEDIATE or HIGH Acute or Chronic Risk but, are deemed to be safe to discharge to home from the ED will be required to have:

• A Suicide Prevention Safety Plan [See Appendix D] either created or updated in the CPRS during their ED visit using the Suicide Prevention Safety Plan Note or the national Suicide Prevention Review/Decline Note (for updates/reviews). Veteran who decline to complete a Safety Plan in ED, staff should document refusal on the national Suicide Prevention Review/Decline Note documenting Safety Planning efforts and Veteran’s reason.

• ED staff should ensure structured follow-up efforts are in place until the patient has engaged in outpatient mental health care.

o A Mental Health (MH) follow-up appointment in WPB MHC NURSING TRIAGE 1C-251, which will be entered by the ED physician in the quick order set.

o MHC will ensured structured follow-up efforts including at least weekly telephone or in-person contact.

o HIGH Acute or Chronic Risk follow the HIGH Risk for suicide protocol by the Suicide Prvention Team.

• The phone number to the 24/7-day Veteran Crisis Line (VCL)

• In addition, the patient will receive a post-discharge follow up call and encouraged to attend his follow up appointment. At the time of this MCM these follow up calls are being done in

PACT.

• Follow-Up efforts should cease if a Veteran expresses a desure to not be contacted. All efforts should be documented in the medical record

* Engaged in care is defined as either attending one individual outpatient appointment or admission to an inpatient unit or residential program

Reporting Suicide Behaviors and Overdose – See Appendix M

2.) Primary Care Aligned Care Team (PACT)

Veterans must be screened as defined by the mandated three stage suicide risk screening and evaluation process defined above.

The screening is to be completed annually in conjunction with the required depression and PTSD screening. In PACT the primary screen, the PHQ-9 Item #9 has been added to the current Depression Screen (PHQ-2) and PTSD Screen (PC-PTSD-5) in the Clinical Reminder System. If a positive depression screen is identified, a warm hand off must be given to the primary care provider to complete the secondary screen using the Clinical Reminder System. In addition, the clinical reminder must be done in CPRS prior to the Primary Care Provider starting his/her note to ensure it will trigger the Follow up Reminder which has the secondary screen, the Columbia C-

SSRS.

The secondary screen, the Columbia (C-SSRS) is performed using the Clinical Reminder System (Titled: Follow-up for Pos PTSD/Depression/SI). If the C-SSRS is positive, a warm hand off should be made to a Primary Care Mental Health provider (PCMHI) who needs to do a Comprehensive Suicide Risk Evaluation the same day. If the Veteran is deemed as INTERMEDIATE or HIGH Acute Chronic risk for suicide, a Suicide Prevention Safety Plan needs to be completed. If Veteran is at imminent risk of suicide he or she must be escorted to the ED with a warm hand off for further MH evaluation.

Primary care staff is responsible for reporting any patient with suicidal ideation or feelings of hopelessness to the primary care physician/provider/nurse manager/designee.

Safety Plan – See Appendix D

Health & Welfare Procedures – See Appendix L

Reporting Suicide Behaviors and Overdose – See Appendix M

3.) Home Based Primary Care/Medical Foster Home:

For consults/intakes, at WPB HBPC, enrollment/admission is completed by the HBPC SWER and the HBPC MD. The HBPC SWER usually completes and documents the primary screen (PHQ2+I9, & PC-PTSD+I9) using the clinical reminder system as part of the admission and on an annual basis. If the primary screen is positive, the HBPC SWER completes the secondary screen (C-SSRS) and documents its completion with the follow-up clinical reminder (Titled: Follow up Pos PTSD/depression/SI) as it requires a statement of disposition. If the secondary screen is positive (C-SSRS) then the HBPC SWER completes the CSRE and as appropriate the Suicide Safety Prevention Plan or notifies the HBPC PSYCH who then completes the CSRE and the Suicide Safety Prevention Plan per protocol.

In the case where an HBPC RN completes a screening for depression (PHQ2 & I9) and the primary screen is positive the HBPC RN will complete the secondary screen (C-SSRS) and document their findings in their HBPC NURSING clinical note. If the C-SSRS screen is positive, then the HBPC RN will notify a LIP who will need to complete, same-day, the follow-up clinical reminder as it requires a statement of disposition. In this case the LIP should speak with the Veteran directly (e.g., by phone, clinical video technology, face-to-face) before completing the clinical reminder and would need to complete the CSRE as discussed below.

Important note: The primary screen (I9, on its own or in conjunction with PHQ-2 or PC-PTSD-5) is not intended to be asked of every Veteran at every HBPC visit. These tools may be used as part of clinical evaluation activities in response to signs or symptoms of mental distress.

Veterans with dementia and documented moderate to severe cognitive impairment (FAST Score >5) are excluded from these screening requirements, as these Veterans may not be able to understand or respond accurately to the screening questions. (Teams, however, should attend to behavioral signs and symptoms of depression, PTSD, and/or suicide risk among Veterans with cognitive impairment and evaluate and provide care as indicated.)

If an HBPC team member is concerned about imminent risk of harm (e.g., the individual is describing suicidal ideation with intent in that moment, is acutely psychotic and/or hearing command hallucinations, or the individual is requesting urgent MH care), EMS should be activated immediately. If the team member is at the home they should stay in the home until emergency services arrive, as long as they feel safe to do so. If the team member is not at the home they should report the situation to the VA Police and then contact local Sheriff/Police for a health and welfare check and then follow up with emergency services to ascertain disposition of veteran.

If there are questions about safety and risk management, and the HBPC MH professional, local Suicide Prevention Coordinator, or other designated MH coverage is not immediately available for consultation by phone, the team member in the home should be encouraged to consult with the Veterans Crisis Line, along with the Veteran and/or Caregiver (800-273-8255, press 1).

A Comprehensive Suicide Risk Evaluation (CSRE) must be done for all consult/intakes/assessments if the C-SSRS is positive, once any immediate risk concerns necessitating EMS activation are addressed. The comprehensive evaluation (CSRE) guided by the standardized CPRS template must be completed the same day by an LIP (HBPC MD, ARNP, PA, SWER, and/or PSYCH:

Psychologist/Psychiatrist) and can be completed face-to-face, by phone or via CVT/VOD, if available. A Suicide Prevention Safety Plan must be completed for all CSREs with a High or Intermediate Risk for Suicide.

Safety Plan – See Appendix D Health & Welfare Procedures – See Appendix L Reporting Suicide Behaviors and Overdose – See Appendix M

4.) Acute Medicine/Surgery Inpatient Wards:

Veterans must be screened using the Three Stage Process defined above. In inpatient settings, patients must be screened upon admission and prior to discharge. If the patient was screened within the past 24 hours, they do not need to be screened again.

If the primary screen is positive, the secondary screen needs to be performed the same day. If the secondary screen, C-SSRS, is positive, a Veteran should be placed on one-to-one observation and a consult for Inpatient Mental Health submitted.

A Mental Health provider must do a Suicide Risk Evaluation using the Suicide Risk Evaluation – Comprehensive note template in CPRS on the same day as the primary and secondary screen unless it is not logistically feasible or clinically appropriate in these situations after ensuring patient safety it is acceptable to complete the CSRE within 24 hours of the positive secondary screen.

A Suicide Prevention Safety Plan must be completed on all CSREs with a High or Intermediate Risk for Suicide.

During report at the change of shift, nursing staff must be made aware of patients on their unit with an active high risk flag for suicide.

Veterans with dementia and documented moderate to severe cognitive impairment (FAST Score >5) are excluded from these screening requirements, as these Veterans may not be able to understand or respond accurately to the screening questions. (Teams, however, should attend to behavioral signs and symptoms of depression, PTSD, and/or suicide risk among Veterans with cognitive impairment and evaluate and provide care as indicated.)

Prior to discharge, Veterans must be screened again using the same Three Stage Process above. Note, when transferring directly from inpatient medicine to inpatient mental health, if the C-SSRS was administered at any time during the inpatient medicine stay, no additional screening is required at the point of transfer to inpatient mental health.

Veterans with a high risk for suicide flag, admitted to Acute Medicine with a mental health diagnosis as their chief complaint must be given 4 follow-up appointments in Outpatient Mental Health when they are discharged, unless they are transferred to the psychiatric ward prior to discharge.

Safety Plan – See Appendix D

Reporting Suicide Behaviors and Overdose – See Appendix M

5.) Outpatient Mental Health Clinics [MHC, PTSD, SUD, PRRC, MHICM (See appendix Q for Nexus Clinics):

Consults/Intake: All consults/intakes in any Mental Health Clinic requires a suicide risk evaluation using the progress note title Suicide Risk Evaluation – Comprehensive (CSRE). This evaluation process must include a clinical impression of both acute and chronic risk using the Risk Stratification Table (See Appendix E).

The CSRE is required by accreditation standards to document risk and protective factors and history of suicidal ideation, intent, plan, and attempts. The CSRE Initial only has to be done once in the Veteran’s lifetime. Thereafter, as clinically indicated an Update CSRE, an abbreviated version of the CSRE can be completed that would update only those risk and protective factors that may have changed, the clinical impression of acute and chronic risk, and the interventions/mitigation plans as clinically indicated.

Existing Patients: The Clinical Reminders for Depression and PTSD include the Item #9 question which is the primary screen and must be completed IF it is due. If the primary screen is positive, the secondary screen, C-SSRS, in the clinical reminders must be done.

The secondary screen clinical reminder is titled “Follow up pos PTSD/Depression/SI.” If this C-SSRS is positive, the Suicide Risk Evaluation – Comprehensive must be completed the same day. The Suicide Risk Evaluation – Comprehensive note template Initial is only required once in the Veteran’s lifetime. Thereafter, an Update CSRE, an abbreviated version of the CSRE can be completed that would update only those risk and protective factors that may have changed, the clinical impression of acute and chronic risk, and the interventions/mitigation plans as clinically indicated.

Veterans determined to be intermediate or high risk needs to have a Suicide Prevention Safety Plan completed. See Appendix D for safety planning.

Veteran deemed to be high risk for suicide by a licensed independent practitioner and is considered to be at imminent risk should be considered for a Baker Act, (see Appendix F for Baker Act Procedure) and escorted to the Emergency Department with a VA Police escort for an acute psychiatric hospitalization.

If a non-clinical MH staff comes in contact with a Veteran who appears to be in psychological distress the following actions need to be taken: Determine if the Veteran has a MH provider/team, and if so contact the provider (Psychiatrist, Psychologist, Nurse Practitioner, Social Worker, or Case Manager). If an assigned MH provider/team is available escort the Veteran to appropriate outpatient clinic and do a warm handoff to the clinic Triage Nurse or other designed same day access Provider. If their provider is not available, Veteran must be seen by the walk-in covering provider. Never leave a potentially high-risk Veteran alone.

Managing Veterans with a High Risk for Suicide Flag

All Veterans with a High Risk for Suicide Flag must have some form of mental health contact at least one time per week for the first 30 days. Face to face contact is strongly encouraged and scheduled.

However if for some reson the Veteran can not come to a scheduled session, mentalh health contact can be made via phone, Video on Demand or Outreach. Veterans are to be seen or have a mental health contact weekly for the first 30 days after the activation of the flag and discharge from the hospital and then monthly thereafter.

All Veterans with a high risk flag must have an updated Risk Assessment monthly until the flag is inactivated (e.g., CSRE). A CSSRS may be completed on a monthly basis as a tool to assess risk however, if the CSSRS is positive the provider must complete the CSRE. If the CSSRS is negative, the Suicide Prevention Safety Plan must be completed or reviewed using the template to ensure identification of risk and protective factors.

If a Veteran no shows one of his post hospitalization discharge MH follow-up appointments the clinical provider must make three attempts to reach the Veteran that day and document it in CPRS.

If the Veteran cannot be reached by phone, the provider/clinician should consider the use of a Health and Welfare Check based on their clinical judgment and chart review. It is the provider’s/clinician’s responsibility upon initiation of the Health and Welfare Check to follow-up on the disposition of the wellness check and keep the Suicide Prevention Team abreast of information.

If a Veteran calls to cancel his post hospitalization discharge MH follow-up appointment without discussing it with the provider/clinician, the clinical provider should make a reasonable effort to speak with the Veteran by phone to assess his/her risk of suicide and encourage Veteran to reschedule the appointment.

If travel or health issues are an obstacle consider scheduling CVT or VOD.

Safety Planning – See Appendix D

Health & Welfare Checks – See Appendix L

Reporting Suicide Behaviors – See Appendix M

6.) MH RRTP/ General Domiciliary

Screening and Pre-Admission:

The Columbia – Suicide Severity Rating Scale (C-SSRS) must be completed at the time of screening. For patients with a positive score on the C-SSRS, a Suicide Risk Evaluation - Comprehensive (CSRE) must be completed during the same session by the provider.

If completion of the CSRE is outside of the scope of practice of the clinician completing the C-SSRS, the clinician should facilitate a warm handoff to a licensed provider with the appropriate scope of practice or credentialing to be able to complete a formal assessment and the CSRE. The list of providers able to complete by CSRE can be found above on Appendix O. Based on the CSRE, appropriate interventions/mitigation plans should be implemented.

NOTE 1: A positive C-SSRS by itself should not serve as a reason for denial of admission. Further, with the exception of Veterans assessed to be at high acute risk requiring acute inpatient mental health admission, findings of the CSRE must not serve as the sole reason for denial of admission.

When a Veteran is required to wait greater than 7 days for admission, weekly screening for change in suicide risk must be performed. At a minimum, this process must include completion of the Patient Health Questionnaire – 9 item (PHQ9) Question 9.

During Admission

A Suicide Risk Evaluation – Comprehensive (CSRE) must be completed within 24 hours following admission for all Veterans, regardless of results of past screening. When completing the CSRE, clinicians must consider aspects of the residential environment of care when developing the intervention/mitigation plan. This is an accreditation requirement by The Joint Commission.

The CSRE must be completed by a licensed independent provider whose defined scope of practice allows for completion of assessments.

See qualified providers in Section II B, Appendix O.

National MH RRTP policy requires screening for suicide risk during a residential stay at defined time points: treatment plan updates, prior to leaving the facility on pass, as clinically indicated, or when there has been a change in the Veteran’s status. To meet these requirements:

• The PHQ-9 Item 9 should be administered at a minimum at the time of treatment plan updates. For Veterans with a positive response to Item 9, the C-SSRS must be completed.

For Veterans with a positive score on the C-SSRS, the CSRE must be updated the same day unless it is not logistically feasible or clinically appropriate in these situations after ensuring patient safety it is acceptable to complete the CSRE within 24 hours of the positive secondary screen.

The CSRE must include a clinical impression of both acute and chronic risk and intervention and mitigation plans as clinically indicated.

• MH RRTPs/Dom also at a minimum must complete the PHQ-9 Item 9 within 48 hours of a non-routine pass that authorizes the Veteran to go into the community without VA staff. When Veterans routinely go into the community as part of their care plan, weekly completion of the PHQ-9 Item 9 is sufficient.

• Routine passes reflect program policies and procedures that allow Veterans to regularly leave facility grounds with approval multiple times during the week (e.g., housing search, employment, mutual support meetings).

• Non-routine passes include weekend or overnight passes or instances where a Veteran leaving the unit is not a regular part of his/her care plan.

Safety Planning for MH RRTP

In addition to Safety Planning outlined in Appendix D, the following applies to MH RRTP/Domiciliary. It would not be uncommon for a Veteran to be admitted to an MH RRTP with a safety plan currently in place. When a Veteran is admitted to the MH RRTP with an existing safety plan, the safety plan must be reviewed at the time the CSRE is completed and updated to account for any changes needed in the residential setting.

Discharge

An updated CSRE must be completed no more than 24 hours prior to discharge. When a Veteran leaves the program without speaking to staff or fails to return from a pass, screening for suicide risk must occur during the next clinical contact with the Veteran (by phone or in person).

The CSRE must be updated at the time of discharge and incorporate interventions and mitigation plans to be in place following discharge. If a Veteran has a safety plan, this also must be updated prior to discharge, addressing any necessary changes for the outpatient setting of care.

Pass Considerations:

Time periods where Veterans are away from the unit have been identified as periods of vulnerability for adverse events occurring including suicide attempts, suicides, overdoses, and overdose deaths. In June 2017, programs were asked to implement routine screening for suicide risk prior to Veterans leaving on pass. The guidance provided in this document is meant to clarify that requirement.

It is important to integrate screening for suicide risk prior to pass as a routine component of pass planning and not an automatic reason for which a pass will be denied. The information obtained as part of the screening process can facilitate the development of risk mitigation strategies implemented prior to a Veteran leaving on pass. Such strategies may include:

• Calling a sponsor every day while on pass

• Putting the unit phone number and Veterans Crisis Line number in the Veteran’s phone prior to pass with encouragement to call if needed

• Scheduling check-ins by phone with the RRTP team while on pass

• Engagement of family members or friends in the pass planning process

Safety Planning – See Appendix D

Health & Welfare Checks – See Appendix L

Reporting Suicide Behaviors – See Appendix M

7.) Inpatient Psychiatric Ward:

In inpatient settings, patients must be screen upon admission and prior to discharge, using the Suicide Risk Evaluation –

Comprehensive (CSRE). When a Veteran is determined to be a high risk for suicide:

• High Acute Risk for suicide should be placed on one to one observation.

Please refer to MCM 548-118-163 PATIENT OBSERVATION LEVELS 1:1 AND 2:1.

In addition to Appendix D requirements for Safety Planning, all patients, who are determined to be a High Risk for Suicide and a Flag has been activated while inpatient, must have a Safety Plan or Safety Plan Review completed within seven (7) days of flag activation and must be updated within 24 hours prior to discharge.

The process of safety planning begins at admission, as clinically appropriate, and is interactive.

All patients with high risk discharge must be given four (4) scheduled weekly follow-up appointments for the first month and then monthly thereafter until the flag is inactivated. All Veterans with a high risk flag must have an updated Risk Assessment monthly until the flag is inactivated (e.g., CSRE). A CSSRS may be completed on a monthly basis as a tool to assess risk however, if the CSSRS is positive the provider must complete the CSRE. If the CSSRS is negative, the Suicide Prevention Safety Plan must be completed or reviewed using the template to ensure identification of risk and protective factors. Patients admitted for acute mental health care who are currently flagged as high risk for suicide at another facility will be assigned a suicide high risk flag by the SPC team while receiving care in WPB VAMC. SPC will coordinate the transfer of the flag to this facility. The inpatient psychiatry treatment team and the SPC team will consult about patients as needed. SPC is a member of the treatment team.

Safety Plan – See Appendix D

Health & Welfare Procedures – See Appendix L

Reporting Suicide Behaviors and Overdose – See Appendix M

8.) Community Living Center

Veterans must be screened using the Three Stage Process defined above. In residential and inpatient settings, patients must be screened upon admission and prior to discharge from the ward.

Note: if the patient was screened within 24 hours, they do not need to be screen again. For example, if the Veteran was screened upon discharge from acute medicine and sent to CLC for rehabilitation and the screening was done within 24 hours, it does not have to be done upon admission in the CLC.

If the primary screen is positive, the secondary screen needs to be performed the same day unless it is not logistically feasible or clinically appropriate in these situations after ensuring patient safety it is acceptable to complete the CSRE within 24 hours of the positive secondary screen. If the secondary screen is positive, Veteran should be placed on one-to-one observation and a Mental Health consult submitted. A Mental Health provider must do a Suicide Risk Evaluation using the Suicide Risk Evaluation

– Comprehensive note template in CPRS on the same day.

All nursing employees on any unit will be made aware of all patients on that unit who are on suicide risk at the change of shift report and any time this status is initiated for a patient.

Other members of the interdisciplinary team will likewise be notified as soon as possible.

Veterans with dementia and documented moderate to severe cognitive impairment (FAST Score >5) are excluded from these screening requirements, as these Veterans may not be able to understand or respond accurately to the screening questions. (Teams, however, should attend to behavioral signs and symptoms of depression, PTSD, and/or suicide risk among Veterans with cognitive impairment and evaluate and provide care as indicated.)

Safety Plan – See Appendix D Health & Welfare Procedures – See Appendix L

9.) Pain Clinic

Veterans must receive the three stage suicide risk screening process defined above upon initial intake into the Pain Clinic and as clinically indicated thereafter. If the secondary screen is positive, Veteran should be seen by a PCMHI Provider or be escorted to the Emergency Department for further psychiatric and suicide risk evaluation the same day. A warm hand-off is required. Note:

I9 should be completed during intake evaluation if greater than 30 days from referral as clinically indicated.

10.) Sleep Clinic

Veterans must receive the three stage suicide risk screening process defined above upon initial intake into the Sleep Clinic and as clinically indicated. If the secondary screen is positive, Veteran should be escorted to the Emergency Department for further psychiatric and suicide risk evaluation the same day. A warm hand-off is required. Note: I9 should be completed during intake evaluation if greater than 30 days from referral as clinically indicated.

11.) COMMUNITY BASED OUTPATIENT CLINICS (CBOC’S):

Veterans will be screened as defined by the mandated three stage suicide risk screening and evaluation process defined above. In PACT including CBOCs the primary screen, the PHQ-9 Item #9 was added to the current Depression Screen (PHQ-2) and PTSD Screen (PC-PTSD-5) in the Clinical Reminder System.

If a positive depression screen is identified, a warm hand off must be given to the Primary Care Provider to complete the secondary screen using the Clinical Reminder System.

The secondary screen, the Columbia (C-SSRS) is performed using the Clinical Reminder System (“Follow-up for Pos PTSD/Depression Screen”). If the C-SSRS is positive, a warm hand off will be provided to Primary Care Mental Health provider (PCMHI) or designee. The Mental Health Provider must complete a Suicide Risk Evaluation – Comprehensive the same day. If Veteran is at imminent risk of suicide he or she must remain on 1:1 observation and call

911. If Veteran is determined to be intermediate or high risk determine the level of care and treatment needed.

Any CBOC staff is responsible for reporting any patient with suicidal ideation or feelings of hopelessness to the mental health provider, primary care provider, nurse manager, or designee.

Veterans with dementia and documented moderate to severe cognitive impairment (FAST Score >5) are excluded from these screening requirements, as these Veterans may not be able to understand or respond accurately to the screening questions. (Teams, however, should attend to behavioral signs and symptoms of depression, PTSD, and/or suicide risk among Veterans with cognitive impairment and evaluate and provide care as indicated.)

12.) Port St Lucie PTSD Clinic Team (PCT):

Veterans will be screened as defined by the mandated three stage suicide risk screening and evaluation process defined above. In PACT including CBOCs the primary screen, the PHQ-9 Item #9 was added to the current Depression Screen (PHQ-2) and PTSD Screen (PC-PTSD-5) in the Clinical Reminder System.

If a positive depression screen is identified, a warm hand off must be given to the Primary Care Provider to complete the secondary screen using the Clinical Reminder System.

The secondary screen, the Columbia (C-SSRS) is performed using the Clinical Reminder System (“Follow-up for Pos PTSD/Depression Screen”). If the C-SSRS is positive, a warm hand off will be provided to Primary Mental Health provider (PMH) or designee. The Mental Health Provider must complete a Suicide Risk Evaluation – Comprehensive the same day. If Veteran is at imminent risk of suicide he or she must remain on 1:1 observation and call 911. If Veteran is determined to be intermediate or high risk determine the level of care and treatment needed.

Any PCT staff is responsible for reporting any patient with suicidal ideation or feelings of hopelessness to the mental health provider, primary care provider, nurse manager, or designee.

Veterans with dementia and documented moderate to severe cognitive impairment (FAST Score >5) are excluded from these screening requirements, as these Veterans may not be able to understand or respond accurately to the screening questions. (Teams, however, should attend to behavioral signs and symptoms of depression, PTSD, and/or suicide risk among Veterans with cognitive impairment and evaluate and provide care as indicated.)

Safety Plan – See Appendix D Health & Welfare Procedures – See Appendix L

D. Other:

Suicidal ideation and attempts will be entered on the patient’s problem list by the provider.

Any patient deemed high risk for suicidal behaviors will have a Category I patient record flag activated on his/her electronic medical record according to VHA Directive 2008-036 by suicide prevention staff. The high-risk flag will be removed by suicide prevention staff when the patient stabilizes to his/her baseline, according to the clinical provider team, and it is past the first 90 calendar days.

The Medical Center Risk Manager and/or the Patient Safety Officer will be contacted by staff for review of actual or attempted suicides within one (1) working day of notification of the incident. A Patient Incident Worksheet (PIW) will be completed by clinical and non-clinical staff on all suicidal behaviors including attempts and completed suicides, whether occurring in or out of the Medical Center facility. The PIW will be submitted to Quality Management through the staff member’s supervisor.

A Behavioral Autopsy review must be completed on all suicides by the Suicide Prevention Team. The review will focus on support and education. If the Morbidity & Mortality review suggests that an administrative investigation be conducted, recommendation for this will be made to the Medical Center Director.

Please refer to Appendix O for the Self Directed Violence Classification System.

IV. RESPONSIBILITIES:

The Medical Center Director or Designee is responsible for assuring the facility's compliance with this policy.

Chief, Psychiatry Service or Designee has the responsibility for the oversight of this policy as described under VHA Handbook

1160.01. "Uniform Mental Health Services in the VA Medical Centers and Clinics”, the dissemination of the content of this policy to staff and to report to the Medical Center Director any unusual incidents in the management of patient care.

Program Managers and Supervisors have the responsibility to disseminate the content of this policy to assigned employees.

Clinical Staff, throughout the facility/CBOC, have the responsibility to ensure policy implementation. This is to ensure proper evaluation, with proper referral for further evaluation, within a timely manner. Awareness of risk factors for suicidal behaviors should be strongly exhibited within their direct care procedures.

Mental Health Staff will conduct an in-depth assessment of all patients being referred for suicidal risk factors. Mental Health staff will determine immediate treatment plan for veterans during their time of crisis. Treatment can include medications, outpatient therapy, and inpatient treatment on a voluntary or involuntary basis.

Suicide Prevention Team includes the Suicide Prevention Coordinator (SPC) and Suicide Prevention Care Manager (SPCM). They function as a coordinator of care for patients at suicide risk and as an advisor to the Medical Center Director; Chiefs of Psychiatry, Psychology, and Social Work; program coordinators and staff concerning suicide prevention strategies for individual patients and for the facility, and the community as a whole. They insure, if appropriate, that patients identified as high risk for suicide are placed on the high-risk list/patient record flag and that the flag is reviewed at least every 90 days; resolve consults from the National Suicide Prevention Hotline; and notify Behavioral Medicine Staff of case management needs.

Every medical center employee receives the National Suicide Prevention training course titled "Operation S.A.V.E.”, and/or the Talent Management System (TMS) online "Suicide Risk Management Training for Clinicians." These resources are designed to heighten the awareness of all medical center employees regarding the recognition for warning signs of suicidality in the veteran population. Based on this training, every employee is responsible for assisting any person in the health care system, or on the premises, who demonstrates suicidal behavior. In all cases, a staff member must stay with the patient until an evaluation has been completed and it is either determined that the veteran is safe or someone has accepted responsibility for the patient's care.

Suicide Prevention is Everyone's Business.

V. REFERENCES:

A. VACO Memorandum Eliminating Veteran Suicide:

Implementatino Update on Suicide Risk Screening and Evaluation (Risk ID Strategy) and Safety Planning for Emergency Department (SPED) Initiatives dated October 17, 2019.

B. VACO Memorandum Suicide Risk Screening and Evaluation Process dated May 23, 2018.

C. VACO Memorandum on Suicide Prevention in the Emergency Department (SPED) Suicide Safety Planning and Follow up Interventions dated September 7, 2018.

D. VACO Memorandum on Suicide Prevention Safety Plan, National CPRS Note Templates Implementation dated June 1, 2018.

E. VHA DIRECTIVE 2008-036, Use of Patient Record Flags to Identify patients at High Risk for Suicide, July 18, 2008.

F. VHA DIRECTIVE 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11, 2008.

G. The Joint Commission (TJC), National Patient Safety Goals, current edition.

H. Hospital Memorandum 548-118-163 Patient Observation Levels. Dated 8/14/18

I. The Joint Commission (TJC), Standards BoosterPak for Suicide Risk (NPSG 15.01.01) March 2013

J. The Joint Commission (TJC), Sentinel Alert Event, Issue 56, February 24, 2016

K. VISN 19 Mental Health Illness Research, Education and Clinical Center (MIRECC):

http://www.mirecc.va.gov/visn19/consult/index.asp

VI. FOLLOW-UP RESPONSIBILITY: Chief, Mental Health and Behavioral Health Services (116)

VII. REPORTING STRUCTURE: Suicide Risk Committee to Patient Care

Review Committee to Clinical Executive Board.

VIII. RESCISSION: MCM 548-116-173, dated March 11, 2021.

IX. RECERTIFICATION DATE: March 20, 2019

Melissa A. Sundin, Acting Medical Center Director

Attachments: A - R

Distribution: Electronic

MEDICAL CENTER 548-116-173

WEST PALM BEACH, FLORIDA December 4, 2019

ATTACHMENT A

PRIMARY SUICIDE RISK SCREENING:

PHQ-9 Item #9, “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”

Not At All Several Days More than Half the Days Nearly Every Day

Any response greater than “Not At All” is a positive screen

ATTACHMENT B

SECONDARY SUICIDE RISK SCREENING:

Columbia – Suicide Severity Rating Scale

1. Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?

YES NO

2. Over the past month, have you had any actual thoughts of killing yourself?

YES NO If NO, skip to question 7.

3. *Over the past month, have you been thinking about how you might do this?

YES NO

4. *Over the past month, have you had these thoughts and had some intention of acting on them?

YES NO

5. *Over the past month, have you started to work out or worked out the details of how to kill yourself?

YES NO If NO, skip to question 7

6. *If Yes, at any time in the past month did you intend to carry out this plan?

YES NO

7. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn’t jump)?

YES NO If NO, STOP

a. If YES, was this within the past 3 months?

YES NO

*Screen is Positive if Yes to ANY of the following items: questions 3, 4, 5&6 (Yes to Both), 7&8 (Yes to both)

If POSITIVE, a CSRE is required the same day in ambulatory care settings unless it is not logistically feasible or clinically appropriate in these situations after ensuring patient safety it is acceptable to complete the CSRE within 24 hours of the positive secondary screen.

WEST PALM BEACH, FLORIDA December 4,2019

ATTACHMENT C

COMPREHENSIVE SUICIDE RISK EVALUATION (CSRE)

Does the Veteran appear to be willing and able to answer questions related to the CSRE (consider intoxication, delirium or other factors that may impact responding)?

☐ If yes, proceed with worksheet ☐ If no, indicate reason and proceed with worksheet, documenting all available information, which will be used to make a final risk determination.

Reason: ______________________________________________________________

Suicidal Ideation ☐ How recently did thoughts occur?

Details of the ideation, including frequency: __________________________________________ ☐ Presence of intent: __Yes __No __Unknown/Unclear ☐ Plan: __Yes __No __Unknown/Unclear ☐ If most recent ideation is not the most severe ideation in the past 30 days, comment on details of the most severe ideation in the past 30 days, including frequency, intent and plan.

☐ Access to lethal means (specifically inquire about firearms and if present, you can comment on # and storage): _____________________________________________________________________________

Suicidal Behavior Suicide Attempts Note: If any suicidal behavior is already documented in a Suicide Behavior and Overdose Report (SBOR) or past CSRE, you will not have to document it again in the CSRE.

☐ Describe history of attempts, including #, general dates, and potential patterns (e.g., following argument with loved one, while intoxicated, after relapse, etc.)

☐ For the most recent attempt:

Date and method used: ___________________________________________________________ Was it interrupted:

Was there any injury:

Any care received afterwards: ______________________________________________________

WEST PALM BEACH, FLORIDA December 4, 2019

ATTACHMENT C Page 2 CSRE Cont’d

Outpatient vs inpatient at the time, whether occurred on VA property and whether it occurred within 7 days of discharge from a VA inpatient or residential facility: _______________________

☐ If the most recent attempt was not the most lethal, document the following…