S02 - SOLICITATION ATTACHMENT - D.10 Suicider risk assessment, intervention, and documentation.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

Medical Center Professional Memorandum October 2019 Behavioral Health 11-49

SUICIDE RISK ASSESSMENT, INTERVENTION, AND DOCUMENTATION

I. PURPOSE:

The purpose of this policy is to mitigate risk associated with suicide among Veterans receiving care within the Veterans Health Administration (VHA) by outlining guidelines for assessing suicide risk factors and warning signs, identifying protective factors, implementing interventions based on the assessed level of risk and documenting these efforts in the Veterans Computerized Patient Record System (CPRS).

II. BACKGROUND:

Suicide is the 10th leading cause of death in the United States. An average of 20 Veterans die by suicide each day. Approximately 6 of the 20 were users of Veterans Health Administration services. On average, there are 93 suicides among the general U.S. non-Veteran adult population per day. The burden of suicide resulting from firearm injuries is high. Despite comparatively lower rates, the largest number of deaths by suicide is among middle-age and older adult Veterans. Approximately 65 percent of all Veterans who died by suicide were age 50 or older. Suicide is a public health crisis that causes immeasurable pain among individuals, families, and communities across the country. Suicide is preventable. As such, suicide prevention is VA’s highest clinical priority.

III. POLICY:

Assessment of suicide risk procedures will be completed by all Licensed Independent Providers (LIPs) indicated in this policy to ensure that risk potential and clinically indicated levels of care are evaluated and implemented at appropriate times.

Appropriate intervention and documentation will be reviewed throughout policy below.

IV. DEFINITIONS:

A. Suicide Risk Screening: A relatively brief screening consisting of selected assessment questions that allows the provider to determine whether a comprehensive assessment is warranted. The national standardized screening is the Columbia Suicide Severity Scale (C-SSRS). (See Attachment A).

D10 - MCPM 11-49

Medical Center Professional Memorandum October 2019 Behavioral Health 11-49 Page 2

B. Suicide Risk Assessment: A formal clinical assessment designed to solicit information for determination of acute and chronic risk for self-harm. The national standardized assessment is the VA Comprehensive Suicide Risk Evaluation (CSRE). (See Attachment B).

C. Suicide Prevention Safety Plan: A Safety Plan is a prioritized written list of coping strategies and sources of support that patients can use during or preceding suicidal crises. Veterans flagged as High Risk for Suicide, when suicide has been identified as a clinically relevant issue, Veterans experiencing chronic or extreme stress, crisis or psychosocial stressors assessed to be at risk for suicide in an outpatient setting and determined safe to be discharged home.

(See Attachment C & D).

D. Suicide Safety Plan Review/Decline: note title/template for Suicide Prevention

Safety Plan review or decline.

E. Suicide Behavior and Overdose Report (SBOR):. SBOR will be used as the sole note title for reporting suicide attempts or suicidal behavior. This CPRS note template must be entered by any Veteran Affairs Medical Center (VAMC) employee who receives report of previous suicide attempt(s), suicidal behavior and/or overdose within the previous 12 months. NOTE: the SBOR is to be used to document behavior only. (See Attachment E).

F. Self-Directed Violence Classification System: A standardized system of nomenclature for clinical events related to suicide (See Attachment F).

G. High Risk for Suicide Flag: Category 1 Patient Record Flag indicating highgh suicide risk, assigned to Veterans medical record to communicate current suicidal risk and need for enhanced mental health care for recovery.

curren y.

H. Suicide Prevention Welfare Check: note title/template will be used as the soleole note title for reporting initiating of welfare checks to ensure Veteran safety utilizing community law enforcement. This CPRS note template must be entered by a Veterans Affairs Medical Center (VAMC) employee who initiates a welfare check. (See Attachment I) dical I)

I. REACH VET summarizes information from the Veterans Health Record and uses predictive modeling to identify Veterans at statistical risk for suicide and other negative outcomes. This tool supplements clinical strategies used to identify at-risk Veterans and may help providers intervene prior to these negative outcomes occurring. The REACH VET program:

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a. Helps alert facilities of Veterans at the top 0.1% increased statistical risk at each facility,

b. Summarizes past two years of health record data to streamline clinical review,

c. Provides an additional data point for conceptualization and treatment, and

d. Offers an opportunity to engage Veterans in their own healthcare and make enhancements, as indicated.

V. ACTIONS: (Per staff specific guidance chart below)

A. Assessment of suicidal risk requires the provider to address a number of specific areas pertinent to making an informed judgment about a patient’s acute and chronic risk level.

1. Assessment of risk will be conducted using PHQ-2 +i9, the PHQ-9, i9 and the PC-PTSD 5+i9 as primary screeners.

2. The Columbia Suicide Severity Risk Screen (C-SSRS) will be completed as a secondary screener for positive primary assessments.

The C-SSRS is located in CPRS note templates. In addition to the minimum requirements below, a CSSRS is required in the following circumstances:

a. Positive PTSD or depression clinical reminder,

b. Telephonic or face to face contact with Veterans flagged as high risk for suicide, and/or

c. Report of suicidal ideations (SI) within the last 30 days or a suicide attempt within the last 6 months during outpatient services.

3. If the C-SSRS is positive, the VA Comprehensive Suicide Risk

Evaluation (CSRE) requires completion within 24 hours. See staff specific guidance in chart below.

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B. Primary and secondary screening should be completed according to staff scope of practice. The VA CSRE should be completed by a VHA Health Care Provider, which is defined as a licensed independent provider (LIP) or advanced practice provider.

C. For the admission requirement, the C-SSRS or CSRE can be completed in or by

LIP or approved clinician utilizing the grid below within 24 hours of admission.

D. A clinical judgment that a patient is at risk of suicide must be accompanied by a written plan of care that is consistent with the assessed level of risk and attempts to address the patient’s safety needs in the most appropriate treatment setting possible.

E. In the event the provider/staff believes there is imminent risk of suicide, the patient must not be left alone. Consultation with the mental health team should be pursued in order to coordinate psychiatric admission. When necessary and appropriate, emergency detainment and Involuntary Commitment procedures may also be implemented.

F. In situations where there is a risk of suicide but no imminent risk of self-harm, the provider may take alternative actions such as completion of a consult for mental health treatment, informing and involving someone close to the patient, limiting the patient’s access to a means of suicide (e.g. removing weapons from the home), and increased contact with the patient in order to help him/her through the immediate crisis.

G. In addition to the actions indicated above, all patients who are judged to be at risk for self-directed violence must be offered a Suicide Prevention Safety Plan and provided a copy. The Safety Plan must include appropriate contacts and telephone number(s) for calls during working hours and other times in the event that a crisis or emergency situation arises.

H. Once a patient has been judged to be at risk for self-harm, reassessment of suicide potential should occur on a regular basis as determined by the primary provider’s clinical judgement based on their interactions with the patient. The frequency of reassessment will be determined by the level of risk presented by the patient, including careful consideration of any factors that might imply an increase in the patient’s potential for self-directed violence (e.g. increased

Behavioral Health 11-49 Page 5 depression, recent stressors). The higher the level of risk, the more frequently the patient should be reassessed. As with the initial assessment, all reassessments must be thoroughly documented in the patient’s electronic medical record.

I. In those instances when a patient is failing to improve, is exhibiting worsening depressive symptoms, or is making repeated or unscheduled visits to the clinic or emergency department (ED), interventions such as contacting family members to obtain additional information and offering inpatient hospitalization may be warranted.

J. In situations where a provider is continuing to see a patient after ruling out suicide as relevant issue, it is an acceptable practice to document a passive suicide risk assessment within the standard progress note (e.g. “no evidence of suicidal ideation”, “no suicidal ideation was expressed, or “not suicidal”);

however, the provider should continue to be alert for any changes in the patient’s psychiatric and psychosocial status that would signal the need for a formal assessment of risk. Such changes include, but are not limited to, new or worsening psychiatric symptoms, significant psychosocial stressors (e.g. job, loss, marital difficulties, and financial problems), and a diagnosis of a serious medical condition.

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

Requirement

Emergency Department and Urgent Carea++

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

I9*

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

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

Sleep Clinic I9 at referral or intake

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

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 to home

Inpatient Rehabilitation**

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

Community Living Center**

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

VI. RESPONSIBILITIES:

A. The Behavioral Health Care Line Manager and Suicide Prevention team have the overall responsibility for establishing and communicating the policies and procedures pertaining to Veteran suicides and suicide attempts. The MHEOCC team will ensure that all safety concerns in the design of inpatient psychiatric units are adequately addressed.

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B. The Suicide Prevention Program Coordinator (SPC) Coordinates suicide prevention services with other managers and section chiefs within the Medical Center, is responsible for developing, initiating and implementing new programs of service delivery. Creates, interprets and informs employees of changes in procedure, programs, policies and service delivery. Provides public relations between the VA and State, local, and private agencies, and universities and community education regarding the VA, the Suicide Prevention Program and public health strategies for suicide prevention.

C. The Suicide Prevention team serves as facility subject matter experts and consultant to all services on VA Regulation for suicide prevention assessment, intervention and documentation. SP team provides guidance on activation, inactivation of High-Risk Flags for Suicide and requirements of enhanced mental health care. The SP team serves as a point of contact for the community, High Risk Veterans and VA leadership. The SP team provides education on documentation and risk stratification related to: Comprehensive Suicide Risk Evaluation (CSRE), Suicide Behavior Reports (SBR), Suicide Prevention Safety Plans, and Self-Directed Violence (SDV) Classification System. The SP team will also provide supplemental, case management services to Veterans Flagged High Risk for Suicide.

1. The SP team is responsible for tracking all suicide attempts and Veterans with serious suicidal ideation through the use of a manageable tracking system. The SP team will ensure that all Veterans on the medical center high-risk list are monitored closely by the appropriate provider on a regular basis, per terms stipulated in the Veteran’s treatment team. The SP team, with support from VHA staff, will also track any no-show appointments by these Veterans and assist with rescheduling the Veterans with a follow-up appointment.

2. The SP team is responsible for developing and implementing training for designated medical center employees whose job assignment increases their likelihood of face to face and/or telephone contact with potentially suicidal Veterans. Targeted employees will include staff working in telephone triage, medical center operators, the Administrative Officer of the Day (AOD), and clerical staff working in behavioral health outpatient clinic areas. All new/current VA staff will require mandatory S.A.V.E.

Training in NEO and annual online training for all clinical and non-clinical staff. Supervisory staff is responsible for ensuring that all designated

Behavioral Health 11-49 Page 9 employees complete this training and including it as part of the employee’s competency plan. The SP team will maintain availability to train specific areas and provide required support to ensure these trainings are made available upon request.

3. The SP team develops and implements ongoing education plans for providers, Veterans, families, and members of the community on risk stratification, risk factors and warning signs, protective factors for suicide and treatment options and recommendations.

4. The SP team designee will participate in regularly scheduled environment of care (EOC) rounds on the inpatient psychiatric unit and the emergency room. EOC rounds will identify elements of the environment that may lead to suicidal behavior and follow-up as needed.

D. The Suicide Prevention Case Manager (SPCM) provides Specialty Case

Management for Veterans at elevated risk for suicide, respond to the Veterans Crisis Line, provide face to face clinical assessments and follow-up. The SPCM complete Collaboration/Active Communication with mental health and primary care providers for suicide specific assessment, treatment plan support, safety plan completion, follow-up notes, tracking no show appointments and assistance with rescheduling. SPCM complete monitoring of high-risk Veterans such as weekly contact for Veterans discharged from inpatient units for the first 30 days and monthly contact for veterans flagged as high-risk for suicide to assure continuity of care. All SPCMs provide prompt response to all crisis call referrals received from the Veterans Crisis Line and referral to community resources and VA as appropriate. SPCMs will monitor and ensure implementation of facility SAIL measures.

E. The providers designated in this policy are responsible for carrying out the required procedures in order to ensure the safety of Veterans.

F. The medical center Quality Management office and the SPC will work closely together on, and are responsible for, tracking and trending all cases of suicide completions and suicide attempts by inpatients and outpatient. All service chiefs are responsible for using this data to evaluate and improve clinical processes.

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G. The medical center Patient Safety Manager (PSM) is responsible for convening, coordinating, and reporting the outcomes of Root Cause Analyses (RCA) pertaining to suicides and suicide attempts, with a member of the Suicide Prevention Team being available to serve as an advisor in these cases. The SPC or designee(s), in collaboration with the PSM, is responsible for overseeing annual aggregate reviews involving suicide and suicide attempts based on available reported data collected during designated periods.

VII. High Risk Flags (HRFs):

A. HRFs may be used for patients who are at a high risk for suicide as a means of enhancing Veteran safety and ensuring that providers can incorporate the Veteran’s risk status into treatment decisions for enhanced mental health care.

B. The use of a HRF for Suicide is intended to address immediate/acute clinical safety concerns and is strictly limited to information that is essential for the delivery of appropriate health care. It is important to ensure that a HRF for Suicide is used only for those Veterans who are at high risk for suicide and only for the duration of the increased risk. The HRF for suicide should be removed as soon as it is no longer clinically indicated. This is especially important to minimize the risk of undue stigmatization for the Veteran and to maintain the value of the HRF for Suicide system as an alert to an immediate clinical safety concern.

C. Veterans should be identified as being at high risk for suicide as early as possible in order to provide access to enhanced care and services that may prevent ongoing suicidality. The following, although not exhaustive, provides guidance for the type of patients who may be appropriate for a HRF FOR SUICIDE indicating high risk for suicide:

1. If a Veteran has an event of intentional Self-Directed Violence with suicidal intent within the previous 90 days.

2. Veterans who are determined high risk through a Suicide Risk

Assessment should be considered for placement in the High-Risk Flag list in collaboration with SPC/SPCM and assessing provider.

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3. Veterans who are admitted to inpatient mental health facilities with suicide attempts or strong suicidal ideations should be considered for placement on the high-risk list to assure adequate follow-up post discharge, consisting of a minimum of four visits within thirty (30) days following discharge. A Suicide Prevention Safety Plan should be completed within 7 days of activation of the High Risk for Suicide Flag and/or prior to discharge from the inpatient unit.

4. Veterans who are referred to the SP team from the Veterans Crisis Line

(VCL) or another help line with report of self-directed violence or suicidal behavior.

5. Veterans who are experiencing a crisis in their lives and have a prior history of suicide attempts or behaviors should be considered for placement on the high-risk list.

6. Veterans with severe suicidal ideation (threats of self-harm, suicide identifying specific plans to complete suicide and seeking access means).

D. The recommending or treating clinician will ensure that patients identified as high risk for suicide will receive enhanced follow-up that meets Veteran Health Administration (VHA) standards for patients at high risk for suicide, consisting of a minimum of four mental health visits within thirty (30) days following inpatient discharge or outpatient activation of HRF, 1 mental health visit within 60 and 1 visit within 90 days. In particular, the patient’s provider should consider frequent follow-up appointments, involving significant others as protective factors in the care planning and limiting access to means of self-harm whenever possible.

E. The treating clinician must ensure patients who are referred for a HRF for Suicide during outpatient or inpatient treatment will have a Suicide Prevention Safety Plan completed within 7 days of activation. Should the Veteran decline the Suicide Prevention Plan the Safety Plan Review/Decline note should be completed in CPRS. The Veteran will be provided with a copy of the safety plan and in all cases the safety plan should be developed collaboratively between the Veteran and the provider.

F. The Suicide Prevention team will evaluate HRF for Suicide at least every 90-100 days to ensure the flag is promptly deactivated when the high-risk status is resolved. The Suicide Prevention team will meet at minimum on a monthly basis to discuss progress with current interventions, with more frequent meetings likely, to determine, in consultation with the team members and patient’s provider, Behavioral Health 11-49 Page 12 whether to continue or remove a HRF for Suicide. If the HRF is continued beyond 90 days, the recommending or treating clinician and Suicide Prevention team will ensure that patient receives, at minimum, 1 visit every 30 days.

G. The following is a list of criteria that could warrant removal of an HRF for Suicide:

1. The Veteran’s high-risk status has successfully resolved as evidenced by no current suicidal intent, no specific/current plan, no preparatory behaviors and ability to independently maintain safety during HRF activation period of 90 days. Veteran may have presence of fleeting suicidal ideations, however endorsement of lethal means safety or absence of means, exhibits ability to utilize personal safety plan and adaptive coping skills during stressors or subjective crisis. Mental health treatment documentation suggests decrease in identified warning signs or improved psychiatric presentation (e.g. mood stability, decrease in depressive symptoms, sleep improvement, increased future planning and identified reasons for living).

2. The Veteran has decided to receive care at another VA Medical Center and the HRF has been transferred for continuity of enhanced care.

3. The Veteran has decided to receive care from providers in the community and is no longer followed at this medical center. Suicide Prevention maintained the HRF for the mandated 90-day period, in the event that care was requested.

4. The Veteran declined to participate in any follow-up mental health care as evidenced by chronic no shows or verbalization of disinterest during outreach. Suicide Prevention maintained the HRF for the mandated 90-day period, in the event that care was requested.

5. The Veteran relocated to an area outside of the medical center’s catchment area. The Suicide Prevention team made efforts to assist with accessing care at another VA Medical Center, however Veteran declined.

Suicide Prevention maintained the HRF for the mandated 90-day period, in the event that care was requested.

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6. The SPC and/or mental health provider have been unable to contact the patient by telephone or mail and have been unsuccessful at locating the patient for a period of 30 days from date of high-risk designation, and there are no indications of safety concerns that would warrant a wellness check by police. In the case of wellness check initiation, Veteran determined to be safe or unable to be located by local Police Department.

7. Following comprehensive clinical case review between Suicide Prevention

Team and Veteran's Justice Officers (VJO), it has been determined the Veteran no longer meets criteria as high risk for due to incarceration exceeding 90 days and inability to undergo or engage in VAMC care/assessment. Veteran’s release date is unavailable and is expected to remain safe with legal authorities. Suicide Prevention maintained the HRF for the mandated 90-day period, in the event that care was requested.

H. Once it is determined that the patient no longer meets the criteria for a HRF for

Suicide the HRF for suicide will be removed from the patient’s medical record;

however, the patient can be reconsidered for a HRF for Suicide and high-risk follow-up whenever the patient is once again determined to be at a high risk for suicide. The Suicide Prevention team, mental health treatment team and Veteran will review case prior to deactivation of HRF for suicide. Suicide Prevention team places 90 Day Review Note in CPRS to initiate decision making in conjunction with treatment team.

I. Staff should remain aware that the absence of a high risk for suicide HRF for

Suicide on a patient’s medical record does not preclude the possibility of suicide potential or a suicide attempt. All staff should recognize that any patient may be at risk for suicide regardless of the flag status.

VIII. VETERANS CRISIS LINE:

A. The SPC/SPCM will be notified of referrals from the National Veteran Crisis Line via email, voice mail, and a web-based hotline application. Referrals received during regular administrative hours (Monday through Friday, 8:00 a.m. – 4:30 p.m.) are followed up within 24 business hours of notification. Referrals made after administrative hours, weekends, and holidays, are received by the SP team the next business day and follow-up is provided within 24 business hours.

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B. Upon receipt of the referral notification, the SPC/SPCM, or designee, will review the call details documented by the crisis line responder located on the web-based crisis line application.

C. For calls that require a rescue to be initiated by the hotline responder, the

SPC/SPCM, or designee, will follow up with the medical center police, attempt to contact the Veteran by telephone and, if indicated, a wellness check will be initiated. If the Veteran was taken to a community mental health facility, the SP team, or designee, will make efforts to establish contact with Veteran following discharge to assist with care coordination and evaluate the Veteran for placement on the facility high-risk list.

D. If the Veteran is transferred from a community mental health facility to the medical center’s acute care psychiatry unit, the SPC/SPCM, or designee, will follow up with the Veteran's inpatient treatment team to determine if a high-risk referral is clinically indicated.

E. For non-emergent referrals, the SPC/SPCM, or designee, will ensure that attempts are made to contact the Veteran. If the Veteran has a known mental health provider, the SPC/SPCM, or designee, will inform the provider of the Veteran's call to the hotline and ask the provider to follow-up with the Veteran within 24 business hours and advise the SPC/SPCM, or designee, of the outcome. If the Veteran does not have a mental health provider or the mental health provider is not available to provide follow-up, or if the Veteran is not enrolled in services, the SPC/SPCM, or designee, will provide the necessary follow-up contact.

F. A total of four (4) attempts will be made to reach the Veteran and each attempt will be documented in the Veteran’s medical record. If a message is left for the Veteran, either on voicemail or with another person, the message will include only the Veteran’s name, telephone number, and a request for a return call. No health care information, including information from the crisis line referral should be released without the Veteran's permission. The only exceptions are instances in which it is determined that there is a concern for the Veteran's imminent safety and in those situations the information released should be limited to that which is absolutely necessary to assist with crisis management.

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G. For Veterans who cannot be reached by telephone an outreach letter will be mailed in an effort to engage the Veteran with services and offer assistance with care coordination.

H. If the Veteran is reached by telephone the mental health provider, SPC/SPCM or designee, will evaluate the Veteran's needs and provide assistance as needed and appropriate to address care-related concerns. If during contact with the Veteran there is any indication that the Veteran is in need of emergency medical attention or that the Veteran is an immediate danger to self or others, the medical center police will be contacted, and/or a welfare check initiated.

I. Once follow-up has been completed the SPC/SPCM or designee will complete the appropriate documentation in the Veteran’s medical record and on the web-based crisis line application.

IX. MANAGEMENT OF SUICIDAL VETERANS IN A COMMUNITY BASED

OUTPATIENT CLINICS (CBOC): The following procedures should be followed in situations where CBOC staff has concerns about a Veteran Veteran’s potential for harm to self or others:

A. If there are urgent/imminent concerns about a Veteran’s risk of harm to self or others, a staff person should immediately call 911 or the local police department.

For CBOCs with VA Police present, consult with on-site VA officer for next steps.

B. The Veteran should not be left unattended or allowed to leave the clinic.

C. Staff should not attempt to subdue or detain a Veteran who is violent, hostile, or threatening; however, if there are no safety concerns for staff, a staff person should remain with the patient until emergency assistance arrives.

D. When police arrive at the CBOC, staff should report all relevant observed behavior, including statements made by the Veteran and information provided by family members. This may also include paperwork regarding involuntary commitment.

E. If there is not an urgent/imminent concern regarding the Veteran’s risk of harm to self or others, staff should document the Suicide Risk Assessment and Suicide Prevention Safety Plan, involving the Veteran’s family whenever possible and advise the Veteran to go to nearest ED for further evaluation and treatment.

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F. All such incidents occurring at a CBOC should be reported immediately to the direct supervisor and the SPC/SPCM, or designee.

X. NO SHOW PROCEDURES:

A. Providers are responsible for attempting to contact any Veteran with a HRF for suicide who does not show for a scheduled mental health appointment. The contact must be attempted during the same business day and should be documented in the patient’s medical record. If this attempt is unsuccessful, three

(3) more attempts must be made to contact the patient. After, four (4) unsuccessful attempts, provider should determine if initiation of a wellness check is warranted.

B. In the event the clerical support staff contacts the patient and the patient states that he/she would like to reschedule a missed appointment, the clerical support staff will contact the provider/clinic for rescheduling.

C. If a message is left for the patient, either on voicemail or with another person, the message should include only a request for a return call from the patient. No health care information should be released without the patient's permission.

XI. SUICIDE BEHAVIOR AND OVERDOSE REPORT:

A. The Suicide Behavior and Overdose Report (SBOR) will be used to document and report suicide attempts or suicidal behavior within the previous 12 months.

Suicide attempts that occur within 12 months of the report will be documented in the Suicide Prevention Application Network (SPAN) by the Suicide Prevention Team. The SBOR will be entered as a separate note title, Suicide Behavior Report-Syracuse, in CPRS. The suicide prevention team must also be directly notified of any suicides, suicide attempts occurring on VA campus and/or suicide attempts occurring within 7 days of discharge from the Syracuse VA medical center or VA residential care for completion of an Issue Brief.

B. The Suicide Behavior and Overdose Report should be completed by any clinical provider who becomes aware of the following:

1. A completed suicide, Behavioral Health 11-49 Page 17

2. A suicide attempt within previous 12 months, and/or

3. Suicidal preparatory behavior i.e. purchasing a firearm with suicidal intent.

C. Completed SBORs will be reviewed by SPC/SPCM or designee for determination of patient record flag indicating high risk for suicide.

XII. SUICIDE PREVENTION SAFETY PLAN

A. A safety plan may be conducted at any point in a patient's clinical care; however, a safety plan must be completed for all Veterans presenting for:

1. Psychiatric admission: All Veterans who are admitted to facility inpatient psychiatric unit will have a Safety Plan completed prior to discharge.

2. Outpatient: Veterans whom suicide has been identified as a clinically relevant issue (e.g. a history of recent suicide attempts, recently expressed suicidal ideation).

XIII. TELEPHONE CALLS-SUICIDE:

A. Procedures to be followed in the event that a Veteran calls the medical center threatening suicide, or a family member calls to report a Veteran’s intent to complete suicide. Telephone calls regarding planned or potential suicide will be handled in a uniform manner by all medical center staff, and actions required in response to a suicidal call will take precedent over non-life-threatening situations that staff members may be engaged in at the time of calls. All medical center employees are expected to familiarize themselves with the procedure.

B. Phone Calls During Regular and Irregular Working Hours

1. If a Veteran patient calls the medical center indicating imminent intent to complete suicide, the staff member taking the call should:

a. Determine the identity of the caller by requesting the name and last 4 of the caller’s social security number.

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b. Note the phone number from which they are calling.

c. Note the current address/location from which they are calling.

d. Ask the Veteran if they are experiencing an emotional crisis, imminently suicidal or homicidal.

1. If yes, ask the Veteran if they are willing to present to the local hospital or VAMC emergency room for an immediate assessment.

2. If yes, alert SPC/SPCM, or licensed individual provider (LIP) to triage the call and assist with coordinating facility transport plan.

2. If a Veteran patient calls the medical center and there is no imminent risk of self-harm, the staff member taking the call should:

a. Provide the Veteran with a direct phone number and extension, VCL number (1-800-273-8255, press 1) in the event of disconnection and conduct warm conference call to VCL.

b. Provide a verbal report to VCL responder.

c. Complete a CPRS telephone note and provide report to immediate

Supervisor and SPC/SPCM or designee.

d. If the Veteran refuses immediate assessment and/or transfer and there appears to be an imminent danger of the Veteran committing an act of self-harm, the staff member may contact VAMC Police who will have the police in the Veteran’s local area make a welfare check to the Veteran’s home. Patient contact information along with information able to be gathered regarding nature of call, potential for weapons and other means, etc., should be conveyed to the VAMC Police to assist with the wellness check. Complete a Suicide Prevention Welfare Check template in CPRS. (See Attachment I)

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e. Outlying clinics with no VAMC Police will contact the local police department directly to request a wellness check.

f. If a family member calls to report a Veteran’s intent to harm himself/herself or someone else, the family member should be encouraged to contact 911, the local magistrate for an emergency custody order or bring the Veteran to the medical center. If the Veteran is available and willing, phone contact between the Veteran and an appropriate staff physician or treatment team member will be facilitated by the person receiving the call.

XIV. SPC REPORTING:

A. The SPC/SPCM or designee is responsible for entering completed suicides, suicide attempts and all patients on the facility's suicide high risk list, into the Suicide Prevention Application Network (SPAN) database. Nationally, this data is extracted monthly. A monthly report will be submitted for the following sections:

1. Outreach Report – Provides information on suicide prevention outreach and educational activities.

2. Miscellaneous Report – This report is fluid and is dependent on Congressional requests for information and can change monthly.

XV. SPC COVERAGE:

A. When the SPC is on leave or otherwise unavailable, coverage for administrative and non-administrative functions (e.g. placement/removal of PRF for suicide risk, completion, issue brief reporting) will be provided by the SPCMs or designee with access to suicide high-risk data. Coverage for non-administrative functions (e.g.

crisis coverage, staff clinical consultation, high risk follow-up) will be provided by the covering team member of Suicide Prevention Program.

XVI. REFERENCES:

The Joint Commission 2016 National Patient Safety Goals.

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

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Suicide Risk and Response Card, VHA Office of Mental Health Service.

VHA Directive 1071, Mandatory Suicide Risk and Intervention Training for VHA Health Care Providers.

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

XVII. RESCISSION:

MCPM 11-49 Syracuse VAMC Suicide Prevention Policy dated February 2017.

XVIII. REVIEW DATE:

October 2021

XIX. FOLLOW-UP RESPONSIBILITY:

The Chief, Behavioral Health Care Line and Suicide Prevention Coordinator

Richard W. Salgueiro, FACHE Interim Medical Center Director

Attachment(s)

Attachment A: Primary Screen for Suicide Risk [PHQ-9 item 9, PHQ-2+I9, PTSD-5+I9]

Attachment B: Secondary Screen for Suicide Risk [C-SSRS Screener]

Attachment C: VA Comprehensive Suicide Risk Evaluation, How-To Guidance

Attachment D: Suicide Prevention Safety Plan, How-To Guidance

Attachment E: Suicide Behavior and Overdose Report

Attachment F: Self Directed Violence Classification System

Attachment G: SAVE-T Process

Attachment H: ICD-10 Suicide Behavior

Attachment I: Suicide Prevention Welfare Check

Attachment A

PRIMARY SCREEN FOR SUICIDE RISK [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

PRIMARY SCREEN SCORING

Response of greater than “Not at all” is a positive screen

PRIMARY SCREEN FOR SUICIDE RISK [PHQ-2+I9]

1. Please read each item carefully and give your best response. Over the past two weeks, how often have you been bothered by any of the following problems?

0. Not at all

1. Several Days

2. More than half the days

3. Nearly every day

2. Feeling down, depressed, or hopeless

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

PRIMARY SCREEN FOR SUICIDE RISK [PTSD-5=I9]

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.

For example:

A serious accident or fire A physical or sexual assault or abuse An earthquake or flood A war A Seeing someone be killed or seriously injured Having a loved one die through homicide or suicide

Have you ever experienced this kind of event?

1. Yes

2. No

In the past month have you… 1.Had nightmares about the event(s) or thought about the event(s) when you did not want to?

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that remind you of the event(s)?

3.Been constantly on guard, watchful, or easily startled?

4. Felt numb or detached from people, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

6. Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?

Attachment B

SECONDARY SCREEN FOR SUICIDE RISK [C-SSRS Screener]

Answer both questions 1 & 2

1) Wish to be Dead:

Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.

[Over the past MONTH], have you wished you were dead or wished you could go to sleep and not wake up?

NO

YES

2) Suicidal Thoughts:

General non-specific thoughts of wanting to end one’s life/die by suicide, “I’ve thought about killing myself” without general thoughts of ways to kill oneself/associated methods, intent, or plan.”

[Over the past MONTH], have you had any actual thoughts of killing yourself?

NO (If NO, proceed to question #7) YES (If YES, ask questions 3, 4, 5, and 6)

3) Suicidal Thoughts with Method (without Specific Plan or Intent to Act):

Person endorses thoughts of suicide and has thought of a least one method during the assessment period.

This is different than a specific plan with time, place or method details worked out. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.”

[Over the past MONTH], have you been thinking about how you might do this?

4) Suicidal Intent (without Specific Plan):

Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as oppose to “I have the thoughts but I definitely will not do anything about them.”

[Over the past MONTH], have you had these thoughts and had some intention of acting on them?

5) Suicide Intent (with Specific Plan):

Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.

[Over the past MONTH], have you started to work out or worked out the details of how to kill yourself?

NO (If NO, proceed to question #7)

6) If yes, at any time in the past month did you intend to carry out this plan?

7) Suicide Behavior Question:

In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life?

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

NO (If NO, proceed to scoring)

8) If YES, ask: Was this within the past 3 months?

SECONDARY SCREEN SCORING

A positive C-SSRS (Columbia) score is a ‘Yes’ response to items 3, 4, 6, or 8.

If positive screen determined, administer the VA Comprehensive Suicide Risk Evaluation same day

Attachment C

THE VA COMPREHENSIVE SUICIDE RISK EVALUATION, How-To Guidance:

1. Suicidal Ideation

Tell me about any suicidal thoughts that you have been having lately.

I understand that you have been having suicidal thoughts lately. Tell me a bit more about what has been going on for you.

1.1 How recently have the thoughts occurred:

When is the last time these thoughts crossed your mind? Today? Yesterday? This week sometime? (continue to probe based on response)

1.2 Frequency of thoughts:

And how often are you having the thoughts? For some people, it is multiple times per day, for others it is weekly or every couple of days. There is no right or wrong.

1.3 Details related to plan (if applicable):

If applicable, incorporate specifics based on what the Veteran has already disclosed as you proceed with your interview.

Have you thought about specific ways to harm or kill yourself? If so, tell me more about those thoughts.

Let’s discuss any plans that you have considered as a way to kill yourself.

What plans do you have to act on the thoughts of suicide that you described?

1.4 Access to lethal means: Yes/No

Your plan involves using (e.g., gun, knife, rope, medication, bleach) ________. Do you have easy access to (fill in their selection )__________?

Describe how easy or hard it would be to act on your plan.

Tell me about any guns that you have at your home. How many do you have? Where do you store them and how do you store them?

Tell me about other weapons or tools that you have considered using to harm yourself.

(e.g., knives, ropes) About how much medication do you have stored in your home that belongs to you or someone else?

Do you have plans to obtain (e.g., gun, knife, medication) ______________?

1.5 Presence of intent: Yes/No

Note: intent can use implicit or explicit evidence that the Veteran wishes to die, means to kill him/herself, and understands the probable consequences.

And do you have any intention of acting on these thoughts?

Are you planning to act on your thoughts and plans? If yes, tell me more about this.

2. Suicide Attempt History and History of Preparatory Behavior

2.1 Number of attempts

Have you ever made a suicide attempt before? • If yes, how many times have you attempted suicide?

2.2 Most recent attempt

Tell me about your most recent attempt. When was this?

What did you do to try to kill yourself? (Get specific information about methods used including estimates of the number of pills taken, amount of substances consumed, seriousness of cuts or wounds etc.)

Were you injured as a result of the attempt?

Did someone or something interrupt you?

Describe the care you received after the attempt, if any.

2.3 Most lethal attempt:

*Note: Skip this section if there was only one attempt. If the most recent was the most lethal, you skip this section.

Thank you for that information. Do you consider that attempt to be the most lethal – or the most likely to result in your death – or was there another one that was more lethal?

Please tell me about that attempt. When was this?

What did you do to try to kill yourself? (Get specific information about methods used including estimates of the number of pills taken, amount of substances consumed, seriousness of cuts or wounds etc.)

Were you injured as a result of the attempt?

Did someone or something interrupt you?

Describe the care you received after the attempt, if any.

2.4 History of Preparatory Behavior: Yes/No/Unknown

Note: Inquire about preparatory behavior even if the Veteran has never engaged in a suicide attempt. Examples include: writing a suicide note, giving away belongings, researching means/methods, seeking access to lethal means (e.g., buying/obtaining a firearm, stockpiling medication).

Have you ever done anything other than what you have already told me to prepare to kill yourself, such as writing a note or collecting pills?

3. Warning Signs

Individual factors that signal an acute increase in risk.

It can be helpful to identify thoughts, feelings or behaviors that you tend to have when your suicidal thoughts are getting worse or when you made an attempt previously.

This helps us know when it is time to use some coping skills or get some help.

What kinds of things do you do, think or feel when that is happening for you?

If the Veteran is having a hard time identifying these, Let’s think about the last time you attempted suicide or had an increase in suicidal thoughts, please describe what that felt like.

After you have collaboratively identified warnings signs, Have you been having any of these warnings signs recently?

3.1 Current Direct Warning Signs (if applicable):

Preparations for Suicide Seeking Access or Recent Use of Lethal Means Suicidal Communication Other

3.2 Current Indirect Warning Signs (if applicable):

Anger Anxiety

Feeling Trapped Guilt or Shame Hopelessness Mood Changes Purposelessness Recklessness Sleep Disturbance Social Withdrawal Substance Use

4. Risk Factors

Factors that may increase the likelihood of engaging in suicidal self-directed violence I am going to ask you a few questions to get a sense of what might elevate your risk for suicide and what might be protective for you.

From what you’ve told me, you have__________ stressors that make it more likely to want to kill yourself. (Fill in with what you know about the Veteran’s risks including financial stressors, relationship stress, recent hospitalizations.)

Is there anything we are missing?

4.1 Current Risk Factors

Access to Lethal Means Financial Problems History of Mental Health Hospitalizations History of Non-suicidal Self-Directed Violence History of Suicide Attempt Homelessness Legal Problems Losses Medical Conditions and Health-Related Problems Preexisting Risk Factors (Ex. History of trauma, family history of suicide)

Psychological Conditions (Ex. Mood or affective d/o, personality d/o, SUD) Social/Systemic Problems (Ex. Poor interpersonal relationships, barriers to accessing care, recent change in level of care)

5. Protective Factors and Reasons for Living

Personal qualities and resources that may reduce the risk for suicide. The Veteran’s self-identified reasons for not attempting suicide.

I am also very interested in hearing about your reasons for living. Please tell me more about why you still want to live. What keeps you going?

What are some things in your life that help motivate you to live?

5.1 Specific protective factors and reasons for living options.

Access to and Engagement with Health Care Interpersonal Relationships Positive Personal Traits or Beliefs (Ex. Religious or cultural beliefs, cognitive flexibility.

Social Context Support System (Ex. Community support, family responsibilities)

6. Clinical Impressions

You do not need to ask further questions here, but it is helpful to think about how you will stratify risk to (1) ensure you have enough information and (2) to inform your risk mitigation strategies.

Identification of Acute risk (minutes to days): Low, Intermediate, High Identification of Chronic risk (long-term): Low, Intermediate, High Provide rationale for your selections.

Please reference the Therapeutic Risk Management—Risk Stratification Table for assistance.

7. Disposition/Risk Mitigation Plan

Let’s focus on some things we can do to increase your sense of hope and your desire to live.

Let’s review your safety plan together.

What are things that you can do outside of my office to help alleviate the heaviness that you feel right now? Are there people you can contact? Places you can go?