Section D.14 Memorandum 116A-005 Suicide Prevention and Management of Suicidal Behavior.pdf

Department of Veterans Affairs Memorandum 116A-005 Central Texas Veterans Health Care System (CTVHCS) August 24, 2018 Austin-Temple-Waco Community-Based Outpatient Clinics (CBOCs)

SUICIDE PREVENTION AND MANAGEMENT OF SUICIDAL BEHAVIOR

1. CHANGES: Added para. (1) c to section 7, Added para. (1) e number 3, Attachment B and D added. Attachment sequence updated due to added attachments.

2. RESCISSION: Memorandum 116A-005, dated June 30, 2015.

3. NEXT REVIEW DATE: August 2021.

4. AFFECTED SERVICES: All clinical services, Police Service, and Medical Administration Service (MAS).

5. POLICY:

a. To detect potential suicide risk and intervene early through standardized, routine screening for depression, substance abuse, Post Traumatic Stress Disorder (PTSD) and suicidal ideation.

b. To provide safe, quality care for patients who are at risk for suicide. All CTVHCS employees are responsible for identification and reporting of potential suicide risks, including environmental conditions and patient behaviors. All personnel are to report observations to the appropriate and responsible healthcare provider, and ensure the immediate safety of the identified patient. The healthcare provider will document the observations, evaluate the patient, and take appropriate action to reduce the suicide risk potential.

c. Clinical leadership will review all cases of completed suicide and depending on the specific circumstance and at the discrection of the facility director, a completed suicide may be analyzed by a multi-disciplinary team who will make recommendations for system change as identified. Aggregated suicide attempts will be similarly analyzed.

The Suicide Prevention Coordinator will be notified of all completed suicides, and of all suicide attempts for high-risk monitoring as appropriate.

6. DEFINITIONS:

a. Suicide Prevention: Making every reasonable effort to provide a safe environment free of hazards that could result in self-harm, to include the early identification of suicide risk factors.

b. Suicide Risk Screening: Identifying potential, heightened risk for suicide by using either a brief, clinical evaluation question set, or by mental health clinical assessment. A three-question initial suicide screen (Attachment A) is available for all providers. This screen may indicate the need for a more in-depth suicide risk

CTVHCS Memorandum 116A-005 August 24, 2018 assessment with resultant assignment of risk level which in turn informs disposition planning.

c. Suicide Ideation: Any thought of engaging in suicide-related behavior.

d. Non-Suicidal Self-Directed Violence Ideation: Self-reported thoughts regarding a person’s desire to engage in self-inflicted potentially injurious behavior.

There is no evidence of suicidal intent.

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

The following definitions are taken from the Centers for Disease Control and Prevention’s Classification System:

f. Completed Suicide: Death caused by self-inflicted injurious behavior with any intent to die as a result of this behavior.

g. Suicide Attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

h. Suicidal Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

i. Suicidal Intent: There is past or present evidence (explicit and/or implicit) that at the time of injury the individual intended to kill self and wished to die and that the individual understood the probably consequences of his or her actions.

j. Preparatory Behavior: Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).

k. Non-Suicidal Self-Directed Violence: behavior that is self-directed and deliberately results in injury or the potential for injury to one’s self. There is no evidence, whether implicit or explicit, of suicidal intent.

l. Undetermined Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence.

m. Physical Injury: A bodily lesion resulting from acute overexposure to energy (this can be mechanical, thermal, electrical, chemical, or radiant) interacting with the body in amounts or rates that exceed the threshold of physiological tolerance (e.g., bodily harm due to suffocation, poisoning or overdoses, lacerations, gunshot wounds, etc.). Refer to the classification System for the Centers for Disease Control and Prevention definition.

n. Interrupted by Self or Other: A person takes steps to injure self but is stopped by self/another person prior to fatal injury. The interruption may occur at any point.

7. RESPONSIBILITES and PROCEDURES:

a. Screening populations and frequency:

(1) Outpatients:

(a) All nexus clinic (see Attachment E) patients who, during annual depression screening, score positive (greater than 2) on the PHQ-2 will have a suicide risk screening completed during the same clinic visit with appropriate clinical action based on the results of the suicide assessment.

(b) All nexus clinic patients who score positive (score greater than 3) on the PTSD (PC PTSD) annual screening evaluation will have a suicide risk screening completed during the same clinic visit with appropriate clinical action based on the results of the suicide assessment.

(c) All patients who present to the Emergency Room for treatment will have a suicide risk screening conducted by nursing during their Nursing ED Assessment. A warm handoff to the treating physician will be provided if indicated during this screening (Attachment D).

(d) Any time a care provider becomes aware of a potentially heightened risk of suicide.

(e) MH Clinics:

1. MH providers will use the suicide risk screening as per (a) above when a patient is due for annual depression or PTSD and has a positive score on either of these screens.

2. MH providers will make a clinical determination of suicide risk at each clinic visit and record the clinical assessment in the CPRS progress note.

3. For all patients flagged as high risk for suicide, a suicide risk assessment will be conducted with the results documented in the Suicide Risk Screening template in CPRS during each individual clinical encounter. (Attachment B).

(2) Inpatients: The clinical facts that drive the need for hospitalization are a prior indication of a heightened population level risk for depression and suicide. As such:

(a) All patients admitted to any acute unit/bed section will need to be screened for suicide risk on admission and discharge. Results of the assessment drive further clinical actions.

(b) All patients admitted to any intermediate, long-term, G/EC or NH sections will similarly be screened for suicide risk with an attendant assessment for suicide prior to discharge as above. Results of the assessment drive further clinical actions.

(c) All patients admitted to any MH unit (to include DOM, RRRTP, acute, SMILE) will similarly be screened for suicide risk with an attendant assessment for suicide prior to discharge (including irregular discharge when possible), release for pass, or a change in privilege status. Results of the assessment drive further clinical actions.

(d) In all cases, the fact of, and the results from, the assessment will be recorded in a progress note in CPRS. Providers may choose to use the screening and assessment tools in CPRS (Attachment A, B and C).

8. RESPONSIBILITIES AND PROCEDURES FOR PATIENTS AT RISK FOR

SUICIDE (PATIENT IS PRESENT):

a. Every CTVHCS employee is responsible for reporting any person in the medical center or on the premises who demonstrates suicidal behavior or voices current suicidal ideations. Suicidal behavior or suicide ideations, will be immediately reported to the provider in charge of the patient’s care. If such ideations or behavior present an imminent danger to the veteran or others, the VA police will be contacted immediately as well if the patient is located in Austin, Temple or Waco. In the CBOCs and other CTVHCS facilities, it is appropriate to call the local police at 911.

b. The Suicide Prevention Coordinators are located in Waco, Temple, and Austin, providing coverage to the CBOCs throughout CTVHCS as well. They have the responsibility to promote awareness at the facility about suicide prevention. This includes providing training for non-clinical staff throughout the facility, and coordinating other training programs to provide ongoing education for all staff. The Suicide Prevention Coordinators and Suicide Prevention Case Managers also have the responsibility of assisting the facility in identifying those patients who may be at high risk for suicide, and assuring that the care and monitoring of these patients is intensified.

Responding to consults received from the National Veterans Crisis Hotline and conducting community outreach to promote suicide prevention awareness is also included in the responsibilities of the Suicide Prevention Coordinators and Suicide Prevention Case Managers. The Suicide Prevention Coordinators are also responsible for leading and maintaining a Suicide Postvention Team to provide debriefing and ongoing support for both staff and surviving family members in the event of a suicide completion.

c. Any healthcare provider/staff member who becomes aware of a Veteran who is in the process of attempting suicide, or who has suicidal or self-destructive impulses, should take immediate action to ensure patient safety. The healthcare provider/staff member who observes such behavior should remain with the at-risk patient while requesting assistance. A seriously suicidal or self-destructive patient should never be left alone. A healthcare provider with appropriate clinical skills and authority should be notified about the perceived risk of suicide and complete a Suicide Screen (see Attachment A) to evaluate the degree and imminence of risk. If risk is imminent, and to ensure VA police involvement and proper reporting procedures are in effect, please notify the VA police immediately. If necessary, request their assistance in transporting the patient who is suicidal, and who is or will be placed on one-to-one observation and transported to the Emergency Department (ED)in Temple or safe and secure location in other locations.

d. If any of the questions to the Suicide Risk Screening (Attachment A) are answered in the affirmative, a physician or qualified mental health provider (MD, PA, RN, Ph.D. Psychologist, Master’s prepared Social Worker, LMFTs, LPCs or Psychiatric APRN) is alerted to conduct a further assessment using Attachment C or conducting an independent psychiatric evaluation addressing suicide risk. Such assessment or evaluation will be noted in the patient’s clinical record and include the following factors:

(1) active and passive suicidal ideation;

(2) suicide plans;

(3) degree of current risk;

(4) underlying disorders; and,

(5) significant recent and past history, with appropriate documentation of both presence and absence of these symptoms.

(6) Protective factors (positive future plans, positive social supports, children at home, responsibility to family or others, pregnancy, cultural beliefs, religious/spiritual beliefs, life satisfaction, positive coping skills, positive problem-solving skills, positive therapeutic relationship)

e. While any staff member can initiate action to protect the patient from self-harm, a physician or RN can initiate suicide precautions. If a suicidal incident occurs during the normal work day, this status will be maintained until the patient is thoroughly assessed. The assessment should be completed by a licensed provider within eight hours from the time they were notified, and if indicated by assessment, a psychiatric commitment will be initiated.

(1) For Temple facility: At all times, will escort the patient to the Emergency

Department (ED). Inpatients will be placed on 1:1 SOS Observation precautions by the RN, and the physician will be notified immediately to evaluate and initiate a request for psychiatric consult, as appropriate.

(2) For Waco facility: Outpatients evaluated as suicidal will be escorted to the Mental Health Clinic for psychiatric evaluation during administrative hours. Inpatients will be placed on 1:1 Observation precautions by the RN, and the physician will be notified immediately to evaluate and request a psychiatric consult.

(3) Austin OPC: Outpatients presenting as suicidal at the Austin OPC should be referred to Mental Health Intake Clinic. 1:1 observation will be maintained until appropriate hand-off occurs. If the patient presents as imminently suicidal and involuntary, contact VA police at 56911. The Mental Health Deputies should be called for an on-site evaluation and initiation of Emergency Detention Order. 1:1 observation will be maintained until the appropriate handoff occurs.

(4) CBOCs should call 911 to transport patients to the CTVHCS Emergency Department or the closest psychiatric evaluation unit based in the community. 1:1 observation will be maintained until appropriate handoff occurs. A Mental Health Provider or Primary Care Provider at the CBOC should complete the Suicide Risk Assessment (Attachment C) or may conduct an independent psychiatric evaluation addressing suicide risk. Such assessment or evaluation will be noted in the patient’s clinical record.

f. Reporting Suicide Completions or Attempts:

(1) Notification of Suicide Incident to the Suicide Prevention Coordinator & Patient Safety Manager: Immediate notification of any suicide attempt that occurs on campus or any completion that occurs on campus or within 72 hours of discharge must be made to CTVHCS Executive Leadership by communication through the appropriate supervisory chain of command. This notification includes after hours, weekends, and holidays. Executive Leadership is responsible for immediate notification of the Network Director.

(2) The first clinical person aware of suicide behavior, or who learns of a completed suicide, whether in an inpatient or outpatient setting, will complete a CPRS note, utilizing the shared template titled Suicide Behavior Report. The Patient Safety Manager and/or the Suicide Prevention Coordinator will receive electronic alerts for all events.

g. Ongoing assessment. A healthcare provider will assess patients requiring either type of special observation at least once each day and an order to continue surveillance will be every 24 hours. Provider documentation of the daily assessment of the mental status of a patient on special observation status is required. An RN will chart on the status of all patients on suicide precaution at least once each eight-hour shift.

h. Observation: When clinically indicated, the healthcare provider will order the appropriate level of patient “Suicide Precautions.”

i. Suicide Precautions: Suicide Precautions are indicated for a patient who is identified as suicidal, potentially suicidal, or at imminent risk of physical self-harm.

Suicide precautions will be ordered by a healthcare provider with authority to do so.

Established suicide precaution levels are:

(1) Suicide Precaution Level I (High Risk) (SOS): Level I precaution requires SOS one-to-one care. A staff member will be assigned to the patient at all times. When Level I precautions are initiated, the patient’s personal belongings are searched and potentially dangerous objects are removed. The patient will always be within arm’s length and within direct line of sight of the staff member assigned, to include times while the patient is sleeping or toileting. UNDER NO CIRCUMSTANCES IS THE PATIENT TO BE LEFT ALONE. A staff member assigned to one-to-one special care of a patient will have no other assignment during that specified period of time. Staff assigned to this duty should be alert at all times to prevent patient access to dangerous articles that could be used to inflict self-injury. The patient is restricted to the unit and all visitors are screened by interview for contraband items. Exceptions to patient restrictions are indicated for clinical exams, diagnostic tests, etc., but staff coverage will be sufficient to prevent any self-injurious behavior by the patient while off the unit.

(2) Suicide Precaution Level II (Moderately High Risk): Level II is initiated when the patient verbalizes suicidal ideation with a recent history of a serious suicide attempt and current intent continues, the patient will be designated as at Moderate Suicide Risk Level II. Patients on Moderate Suicide Risk Level will be confined to the Acute Psychiatric Intensive Care Unit unless escorted by a nursing staff member to any urgent medical-surgical or diagnostic appointments. Staff will check Moderate Suicide Risk Level patients at 15-minute intervals. Patients on Moderate Suicide Risk Level II will wear hospital pajamas with or without a robe, but without a belt.

NOTE: Medical and Surgical Areas: The only acceptable level of observation is “arm’s length” coverage by staff with 1:1 Observation (SOS) will be maintained at all times.

Nursing staff assigned to a patient on SOS precautions will remain with the patient until they are relieved by another staff member assigned to 1:1 supervision of the patient by the charge nurse (RN) of the unit.

(3) Suicide Precaution Level III (Moderate to Low Risk): Level III is for Mental Health use only. Patients who verbalize occasional suicidal thoughts throughout the day, although they demonstrate the ability to control their impulses, or patients with a recent suicidal attempt who no longer experience suicidal ideation, will be designated as at Low Suicide Risk Level. Staff will check Low Suicide Risk Level patients at 30-minute intervals until this risk level is no longer needed. Patients at this risk level will not be allowed to leave the Acute Psychiatry ward unless escorted by at least one staff member or a responsible family member (with approval from the Attending Psychiatrist).

Patients on Low Suicide Risk Level will wear hospital pajamas with or without a robe, but without a belt.

j. Removal from, or change in, observation status: Removal from, or change in, observation status will be completed by a physician. Findings will be documented in the chart, and appropriate orders written. No harm contracts with the patient are insufficient justification for removal from special observation status. A patient is never to be removed from suicide precaution status for the convenience of staff or staffing patterns.

k. Patient Rights and Dignity: Special observation status infringes on patient rights to privacy and dignity, and will be used only when clinically justified. Staff will make every effort to protect the privacy, dignity, and rights of the patient on special surveillance status. The rights and liberties of the patient will be observed at all time.

CTVHCS staff will adhere to all appropriate Texas laws concerning involuntary hospitalization and transportation if it becomes necessary to involuntarily hospitalize the patient.

l. Psychiatry Discharge Assessment: When a psychiatry/mental health patient is clinically determined appropriate for discharge (regular or irregular) from any/all inpatient and residential MH programs, the discharging physician will document suicide risk assessment at the time of discharge in the discharge summary. In addition, the nursing staff will conduct a suicide risk assessment, which is included on the nursing discharge note. A patient may be granted a pass or transfer from an acute psychiatry setting to another ward within the facility. In cases such as this, patient safety will be ensured. Patient transfers will include handoff communication between providers specifically addressing whether the patient’s inpatient stay included suicidal ideation and/or suicide attempts. The attending healthcare provider is ultimately the person responsible for ensuring that efforts to make the pass/discharge environment safe have been established and are documented. Prior to approval of patient passes, the provider will make appropriate determination for suicide risk of patient, and document findings in

CPRS.

m. Outpatient Veterans/Veterans Outside the Facility: CTVHCS staff who become aware of serious suicidal behavior in a veteran who is not on the premises is responsible for exercising reasonable care to protect the welfare of the veteran. This may include notification of VA police as well as civil authorities if the danger is seen as imminent. Refer to Attachment G “911 Request or Welfare Check on an Outpatient.”

n. Procedures for Emergency Telephone Call with A Suicidal Patient:

(1) Never transfer the call or place the person on hold unless the patient has given their exact location. Transferring the call limits ability to trace the call.

(2) Procedure for Telephone operator or VA employee who receives call: See Attachment E and F.

(3) Procedure for VA Police: See Attachment E and F.

o. Education:

(1) The Suicide Prevention Coordinators will provide training on the recognition, management of, and the reporting of, suicidal behavior/events for all new employees at

CTVHCS.

(2) Suicide Prevention staff will provide training for all clinical providers on the assessment of suicide risk through the Talent Management System.

(3) All Clinical Service Chiefs are responsible to ensure that their providers and staff are educated on this policy on an annual basis.

p. The Suicide Behavior/Suicide Review Panel:

(1) VA regulations require that all suicides and suicide attempts be reviewed. The Suicide Review Panel is an interdisciplinary group charged with the following responsibilities:

(a) Conducting RCAs of suicide and suicide behavior events assigned by the Patient Safety Officer according to the National Center for Patient Safety (NCPS) guidelines.

(b) Design, recommend, conduct, and promote educational programs to assist medical center staff to improve skills in preventing and managing suicidal behavior.

(c) Collect, trend, and report data regarding suicide behavior events.

(d) Recommend actions to improve the medical center’s ability to prevent and manage suicidal behavior.

(e) Track and report the status of actions taken in response of suicides and suicide behaviors.

(2) Panel membership will consist of individuals who express interest in the phenomenon of suicide, and have a willingness to serve for at least two years on the panel. Mental health disciplines of Psychiatry, Psychology, Suicide Prevention Coordinators, and Nursing will be considered for membership. The Patient Safety Manager will serve as an advisor to the panel.

(a) The Suicide Behavior Suicide review panel will meet monthly, making immediate recommendations to Leadership as appropriate, in addition to those resultant from the annual aggregate reporting.

(b) Aggregate reviews completed by the Suicide Review Panel will be presented to CTVHCS leadership.

q. Suicide Postvention Program: The Suicide Prevention Coordinators are responsible for leading and maintaining a Suicide Postvention Team, charged with offering debriefing and support services for providers and surviving family members affected by the suicide of a Veteran.

9. REFERENCES: VHA Program Guide 1103.3, Mental Health Program Guidelines;

VHA Handbook 1050-1, "VHA National Patient Safety Improvement Handbook”; Station Memorandum 116A-017, "Involuntary Commitment of Patients Under the Texas Mental Health Code," Reducing the Risk of Suicide, JCAHO Resources-CD-ROM, Current Joint Commission Accreditation Standards, Self-Directed Violence (SDV) Classification System Clinical Tool, Centers for Disease Control and Prevention, Memorandum of Agreement for Mental Health Telephone Care Services Between the Veterans Crisis Line and the Central Texas HCS, American Association of Suicidology, Clinician Survivor Task Force Postvention Guidelines for Professionals, June 2010.

/s/ Christopher R. Sandles, MBA, FACHE Director

Attachments: A. Suicide Risk Screening B. Suicide Risk Screening CPRS Template C. Suicide Risk Assessment D. Emergency Department Suicide Risk Screening E. Nexus clinic information F. Emergency Call with a Suicidal Patient G. 911 Request of Welfare Check on an Outpatient

Approved by CEC: 7/17/18

ATTACHMENT A

Suicide Risk Screening

1. Do you have current thoughts about suicide or self-harm?

No

Yes

1. Do you have any current or specific plan for acting on those thoughts?

No Yes Comment:

2. Do you intend to act on these thoughts?

No Yes Comment:

2. Do you have the means to carry out this plan? (i.e.: Do you own a gun?)

No Yes Comment:

3. Do you have a prior history of suicide ideas and/or attempts?

No Yes Comment:

4. Are you feeling hopeless and/or helpless?

No Yes

Comment:

If any of these questions have a "YES" response, refer to provider to complete a full suicide risk assessment and plan of care.

ATTACHMENT B

REQUIRED FOR ALL HIGH RISK VETERANS AT EACH VISIT:

Insert this from Template: “SUICIDE RISK SCREENING” into note:

-------SUICIDE RISK ASSESSMENT-------

Patient’s last suicide risk assessment: _________

No Yes

Do you have any current or specific plan for acting on those thoughts?

No Yes

Comment: xxx

Do you intend to act on these thoughts?

No Yes

Comment: xxx

Do you have the means to carry out this plan?

No Yes

Comment: xxx

2. Do you have a prior history of suicide ideas and/or attempts?

No Yes

Additional information: xxx

3. Do you have a family history of suicide (1st degree relative)?

No Yes

Specify relative: xx

4. Are you feeling hopeless and/or helpless?

No Yes

1. Social or demographic risk factors:

Elderly (+65), young adult (15-24), unmarried, white, living alone, current ETOH and/or drug use, chronic physical disorder/pain, owns firearm, History of physical abuse, History of sexual abuse, History of emotional abuse, same sex sexual orientation, none identified

2. Current areas of psycho-social distress:

Marriage, employment, health (new DX or problem), health (worsening symptoms), finances, legal, none identified

3. Protective Factors:

Positive future plans, positive social support, children in home, responsibility to family, responsibility to other, pregnancy, cultural belief, religious/spiritual belief, life satisfaction, positive coping skills, positive problem solving skill, + therapeutic relationship

Given the veteran's presentation at the time of this assessment and considering the above noted risk and protective factors, in my clinical judgment the veteran's current risk potential for suicidal behavior is:

RATING FOR SELF HARM:

LOW RISK. Patient judged NOT to be at significant risk for self-harm.

MODERATE RISK. Patient judged to be at increased risk of suicide but not acutely dangerous to self.

HIGH RISK. Patient judged to be at acute risk for self-harm.

Plan/Risk Reduction:

▪ Consult Mental Health

▪ Hospitalize (voluntary or involuntarily)

▪ Change/adjust medications o Comment: xxx

▪ Refer for outpatient treatment o Comment: xxx

▪ Increase treatment intensity (frequency of contact)

▪ Increase involvement of support system

▪ Counsel to remove weapons from home (this is required for means reduction)

▪ Provide contact information regarding telephone numbers to clinicians, crisis help lines.

▪ Other: xxx

Where to find Template in CPRS:

ATTACHMENT C

Suicide Risk Assessment

Yes

1. Do you have any current or specific plan for acting on those thoughts?

No Yes Comment:

2. Do you intend to act on these thoughts?

No Yes Comment:

2. Do you have the means to carry out this plan? (i.e.: Do you own a gun?)

No

3. Do you have a prior history of suicide ideas and/or attempts?

4. Are you feeling hopeless and/or helpless?

5. Social or demographic risk factors:(select all that apply)

Elderly (+65) Unmarried living alone current ETOH and/or drug use chronic physical disorder/pain owns firearm History of sexual abuse History of emotional abuse same sex sexual orientation none identified

6. Identify current areas of psycho-social distress: (Describe any checked items) Marriage home and/or family life employment health (new DX or problem) health (worsening symptoms) finances legal

7. Protective Factors: (Describe any checked items)

Positive future plans positive social support children in home responsibility to family responsibility to other pregnancy cultural belief religious/spiritual belief life satisfaction positive coping skills positive problem-solving skills positive therapeutic relationship

RATING FOR SELF HARM*

LOW RISK: Patient judged to be at low risk for self-harm.

LOW RISK: Given the veteran's presentation at the time of this assessment, in my clinical judgment the veteran's current risk potential for suicidal behavior is low and patient is judged not to be at significant risk for self-harm.

MODERATE RISK: Patient judged to be at increased risk of suicide but not acutely dangerous to self.

MODERATE RISK: Given the veteran's presentation at the time of this assessment, in my clinical judgment the veteran's current risk potential for suicidal behavior is moderate and patient judged to be at increased risk of suicide but not acutely dangerous to self.

HIGH RISK: Patient judged to be at acute risk for self-harm.

HIGH RISK: Given the veteran's presentation at the time of this assessment and considering the above noted risk and protective factors, in my clinical judgment the veteran's current risk potential for suicidal behavior is high and patient is judged to be at acute risk of suicide or self-harm. Patient remains under observation until handoff to mental health team.

Should a Mental Health evaluation be deemed necessary during regular business hours, contact your local Mental Health resources located within the clinic or dial 911 for emergent issues. In Temple, after-hours Mental Health assessments should be referred to the Emergency Room where on-call Mental Health services are available.

***Please select and complete "Patient to be evaluated by Mental Health" option, which includes EMERGENT disposition, within the respective "positive screen" below. ***

PROVIDER ASSESSMENT AND PLAN

Based on the results of the patient’s suicide risk assessment, the following plan will be implemented:

Plan and Disposition

No mental health condition requiring further intervention.

Comment:

Already receiving needed treatment. Contact information and instructions for accessing emergency services provided.

Comment:

Patient to obtain treatment outside this VA. Contact information and instructions for accessing emergency services provided.

Comment:

Location:

Patient to be evaluated by Mental Health Immediate Mental Health evaluation needed: care arranged

Urgent Mental Health evaluation (within 24 hours) needed: Referral made, contact information for Mental Health and instructions for accessing emergency services provided.

Comment:

Referral made, contact information for Mental Health and instructions for accessing emergency services provided.

Patient to be treated in Primary Care

Patient to be managed in Primary Care. Contact information for and instructions for accessing emergency services provided.

Medication ordered.

Other:

Further intervention recommended but patient refused. Contact information and instructions for accessing emergency services provided.

ATTACHMENT D

Emergency Department Suicide Risk Screening

Have you wished you were dead or wished you could go to sleep and not wake up within the past month?

Yes

No

Have you had any actual thoughts of killing yourself within the past month?

Yes

Have you been thinking about how you might do this?

Yes

No

Have you had these thoughts and had some intention of acting them?

Yes

No

Have you started to work out or worked out the details of how to kill yourself? Do you intent to carry out this plan?

Yes

No

Warm hand off provided to: __________________

No

Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Yes

Was this within the past 3 months?

Yes

Warm hand off provided to: _________________

ATTACHMENT E

Nexus cohort (Catnums 50, 51, & 52): A patient who meets all of the following criteria is eligible for selection in the random sample as a Nexus clinic patient:

• Veteran was not already reviewed during the current FY and, for the SCI catnum

(52), within last 2-3 months of previous year for an outpatient cohort.

• Outpatient visit anywhere in VHA recorded in AAC File SE at least once during the

13-24 months prior to the study interval. This visit is considered an ‘anchoring’ visit which identifies an ‘established’ patient.

• Seen in the preceding month in any one of the following Nexus designated clinics in either primary or secondary position

323 Primary Care 312 Pulmonary/Chest 303 Cardiology 322 Women’s Clinic 305 Endocrinology/Metabolism 348 Primary Care-group 306 Diabetes 350 Geriatric Primary Care 309 Hypertension 531 MH Primary Care-Indiv 310, Chr Infect. Disease/PC 563 MH Primary Care-Group

Mental Health Clinics 509 Psych MD-Indiv 576 Psychogeriatric Clinic-Indiv 510 Psychology-Indiv 577 Psychogeriatric-Grp 512 Psych Consultation 559 Psychosocial Rehab-Grp 557 Psych MD Group 532 Psychosocial Rehab-Indiv 558 Psychology Group 516 PTSD-Group 502 MH Clinic Indiv 562 PTSD-Indiv 550 MH Clinic Group 519 SUD-PTSD 533* MH Intervention Biomed 503 MH Residential Care 565** MH, Medical Care only-

Group 121 Comm. Resid Care-Med

560 Substance Abuse-Group 552 MHICM-Indiv 513 Substance Abuse-Indiv 567 MHICM-Group 523 Opiod substitute 589 Non active duty sex trauma 540 PCT-PTSD-Indiv 524 Active duty sexual trauma 561 PCT-PTSD Group Day Programs 505 Day Treatment-Indiv 554 Day Hospital 506 Day Hospital-Indiv 578 Psychogeriatric Day Program 547 Intensive SUD 580 PTSD Day Hospital 553 Day Treatment Group 581 Day Treatment

*For use by MH clinicians who provide individual care, primary dx is med rather than psych;

e.g.: chronic pain, essential hypertension, LBP, migraine HA, obesity, etc.

**e.g.: chronic pain, essential hypertension, LBP, migraine HA, obesity, etc.

• Not paired with 160 Pharmacy Consul 710 Flu clinics 691 Pre-employ physical-military 717 PPD only

ATTACHMENT F

EMERGENCY CALL with a Suicidal Patient

Procedure for VA employee who receives the call

1. Alert other staff you are on a suicide call. Have other staff (if available) or yourself call for assistance from an available clinical staff member to assist with the call.

2. Keep the caller on the line and obtain name, last four of social security, phone number and current location of caller. Keep the caller on the line until the appropriate hand off to a clinical provider is made.

3. Remain available until the clinical staff member determines a disposition of the caller should assistance be required in providing a welfare check (see Attachment G). Call the VA Police for assistance in contacting appropriate local police to provide the welfare check if required.

4. Should no clinical staff be readily accessible, hand off the call to the Emergency Department staff, providing the Veteran’s name, last four of social security, phone number and current location of caller, if known. This information is needed should the caller not remain on the line during this hand off and a welfare check is indicated.

5. In the event that Emergency Department staff is unavailable as indicated above, the call may be transferred to the National Veterans Crisis Line (1-800-273-8255). The VA employee handling the call must provide the hotline responder with the Veteran’s name, last four of social security, phone number, and current location of the caller if known.

This warm transfer will aid in locating the Veteran should he need emergency intervention while on the line with the hotline responder.

ATTACHMENT G

Health and Welfare Check Request Guideline

1. Staff will contact the VA police for 911 or welfare assistance. (Austin-56911, Temple-44911, Waco-55911)

2. The VA police dispatch will call the appropriate community police dispatch to request a 911 services or a welfare check on a patient.

3. If the threat is imminent, then contact the local authorities directly for an immediate welfare check. Contact the VA Police immediately after requesting the welfare check so they can follow up.

4. The VA police will obtain from the Mental Health provider the following information:

Provider name, title, and extension: _________________________________________

Veteran’s Name: ________________________________________________________

Veteran’s full Social Security Number: _______________________________________

Veteran’s Address and Phone Number: ______________________________________

What is the reason for requesting the welfare check: ____________________________

Has Veteran expressed a plan for suicide? If so, please describe:

Is Veteran flagged high risk for suicide?

If so, please check on their OMHS High Risk for Suicide Treatment Plan to provide name and phone number of listed emergency contacts:

Has the Veteran attempted suicide before? If so, how? __________________________

Does Veteran have a history of violence? ____________________________________

Does Veteran have access to weapons? _____________________________________

Are there children in the house? ____________________________________________

Where can Veteran most likely be located at this time? __________________________

Does Veteran work? If so, please provide work address and schedule if known:

Please provide make and model of car, if known:

Does Veteran present as being under the influence of alcohol or any illicit substances?

Please explain:

5.VA police will notify the requesting provider of actions taken by the respective law enforcement agency.

6.The requesting provider is to document in the medical record the date and time of call, brief description of the call and any actions taken, including follow up care for the patient.