VA257-17-R-0506-007.doc

D.6 VA257-17-R-0506

DEPARTMENT OF VETERANS AFFAIRS

NORTH TEXAS HEALTH CARE SYSTEM

February 24, 2017

549/116A

VANTHCS MEMORANDUM NO. 116A-01

SUICIDE PREVENTION, ASSESSMENT, AND MANAGEMENT

1.

PURPOSE:

The purpose of this memorandum is to establish policies and procedures for VA North Texas Health Care System (VANTHCS) for effective assessment, intervention, and management of Veterans with suicidality.

2.

POLICY:

It is the policy of VANTHCS to assess and manage individuals with suicidality while under the care of this health care organization.

VANTHCS will implement a standardized approach with regards to safety, assessment and intervention of Veterans concerning self-directed violence, including suicidal ideation, suicidal intent, self-injurious behavior and suicides. All employees are responsible for being aware of the warning signs associated with the various forms of self-directed violence, and for responding appropriately to ensure the best possible clinical outcomes for the Veterans served by VANTHCS.

This policy addresses the following: implementation of strategies to identify Veterans at risk for suicide and the proper assessment, treatment, and management of suicidal patients; processes for evaluation and consultation by Mental Health (MH) staff, appropriate and timely communication from other services to Mental Health, and timely reciprocal communication from MH to other services; use of suicide precautions and one-to-one observation; documentation of relevant information in the Computerized Patient Record System (CPRS); and medical center staff training.

3.

PROCEDURES:

a.

Definitions:

(1) Suicide Risk Assessment (SRA): An estimate of suicidal risk or probability based on protective and risk factors, which identifies areas of strengths or early warning signs that might decrease or increase the potential to self-harm. Also included is an estimated risk level of low, moderate, or high, and a plan for reducing the risk. The SRA is to be completed at the time of a Veteran's initial evaluation, following each change in level of care, and/or as clinically indicated. It is to be completed at each outpatient encounter for any Veteran with the Category I Patient Record Flag High Risk for Suicide.

(2) Suicide Behavior Report (SBR): This will be completed by the first clinical staff member (i.e., Nurse, Nurse Practitioner, Social Worker, Psychologist, Physician or Physician Assistant), when the clinical staff member is made aware of any episode of self-directed violent behavior that was lethal, preparatory or potentially harmful that has not been previously reported or documented. When a SBR is completed, the Computerized Patient Record System (CPRS) automatically notifies Suicide Prevention Coordinators (SPC) of the completed SBR without the need for authors of the SBR to add SPC as co-signers.

(3) Suicide Prevention Safety Plan (SPSP): A prioritized written list of coping strategies and resources developed with and continually available to Veterans who have been deemed to be at an elevated risk for suicide. This plan should be simple, easy to read, using the Veteran's own words and should include warning signs for suicidal risk, internal coping strategies, social and/or family supports to contact, professional resources and/or agencies to contact for help, and what should be removed from the Veteran’s environment to decrease access to means available for use in self-directed violent behaviors.

(4) Category I Patient Record Flag High Risk for Suicide: Veterans whose record is flagged with the Category I Patient Record Flag High Risk for Suicide (PRF) will have a Suicide Risk Assessment and Suicide Prevention Safety Plan completed with a Provider and:

(a) Veterans flagged with a PRF will be monitored and seen by a Provider for at least 90 days after the flagging. The first month of the 90 days, the Veteran will receive four weekly mental health appointments, with the first appointment scheduled within 7 days of when the PRF is placed. During the second and third month of the 90 days, the Veteran will receive at the minimum, one appointment each month and will complete a SRA and SPSP.

(b) At the end of the 90 days from the initiation of the PRF, the PRF may be continued for an additional 30 days, if clinically indicated. The Veteran will be assessed every month after the first 90 days period to determine if the HR PRF should be continued. If the HR PRF is reviewed and discontinued, the frequency of Veteran/Provider visits after removal of the HR PRF will be determined by the Provider and be based on additional reported episodes of self-directed violence, the Veteran’s level of engagement, progress in the mental health recovery process and persistence of reported symptoms.

(c) The use of the PRF is restricted to addressing immediate clinical safety issues. It is important to ensure that usage of PRF is limited to only Veterans at high risk and only for the duration of the increased risk.

b.

Assessment, treatment planning and intervention is determined by the level of risk assessed according to the following:

(1) Acutely suicidal high risk Veteran will be admitted to a Mental Health Acute Inpatient Unit with 1:1 suicide precautions. A Suicide Behavior Report will be entered for any significant instances of self-directed violence, including previously undocumented suicide attempts and/or significant suicidal ideation with a plan that requires an immediate modification of treatment and/or preparatory suicidal behavior. SPCs will review the patient SBR, SRA and SPSP for potential placement of a PRF Category I High Risk for Suicide flag.

(2) Discharge planning from a Mental Health Acute Inpatient Unit for safety should include, but is not limited to:

(a) A Suicide Risk Assessment.

(b) If the Veteran has a PRF, the Veteran will be scheduled for four Outpatient Mental Health appointments within the four weeks following discharge from Mental Health Acute Inpatient Unit (MHAIU).

(c) A completed Suicide Prevention Safety Plan prior to discharge to the outpatient level of care. The Suicide Prevention Safety Plan will be documented in CPRS and the Veteran will be provided a printed copy.

(d) The Veteran will be given the telephone numbers of the Dallas VA Medical Center, the Mental Health Outpatient Clinic where the Veteran is assigned and the Veteran's Crisis Line (1-800-273-8255). The Veteran will receive written instructions of follow-up appointments for continuity of care.

(e) Documentation of the steps taken to address issues that precipitated the inpatient admission and/or reported self-directed violence.

(f) Documentation of post-discharge treatment goals and anticipated interventions.

(3) Management of Safety at an Outpatient Level of Care:

(a) If a Veteran presents in person to any staff member and discloses that he/she experienced, has been experiencing suicidal or is experiencing thoughts/behaviors/intent/plan or expresses significant emotional distress, the staff will maintain visual contact with the Veteran, remain engaged with the Veteran and offer an assessment with a Mental Health Provider.

(b) If the Veteran agrees to an assessment by a Mental Health Provider, the staff member with whom the Veteran had initial contact maintains continuous visual contact with the Veteran until there is a warm handoff to a Mental Health Provider. Staff should perform a warm handoff directly to an available Licensed Mental Health Provider. If there is not a Licensed Mental Health Provider available and accessible, the Veteran will be escorted to the Emergency Department (ED), a Mental Health Clinic, or Primary Care Mental Health Integration (PCMHI) to receive an immediate assessment. The staff member escorting the Veteran will explain the urgency of the situation to the reception staff and remain with the Veteran until the Veteran is received by a Licensed Independent Provider (LIP). The LIP will complete a Suicide Risk Assessment and will determine the appropriate clinical course of action.

(c) If the Veteran refuses to meet with a Mental Health Provider or leaves the area after disclosing suicidal thinking or other self-directed violence, the staff member will notify the Primary Care Provider. At the Dallas VAMC, Fort Worth Outpatient Clinic and Sam Rayburn Memorial Veteran Center, staff will alert the VA Police. Local police should be notified if the occurrence transpires at the Plano, Denton or Tyler Outpatient Clinics. VA and/or local police will provide assistance, as appropriate. In addition, the staff member will alert their direct supervisor. If the Veteran leaves the area and cannot be located, staff will follow procedures on MCM NO. 118A-09, Management of Missing Patient, to determine follows up actions.

(d) Veterans who are flagged with the HR PRF High Risk for Suicide while at the outpatient level of care will have a Suicide Risk Assessment and Suicide Prevention Safety Plan completed by a provider when seen by a Mental Health Provider.

(4) Emergency Department (ED): All Veterans presenting to the ED with symptoms of suicidal thoughts or other self-directed violence will receive a Suicide Risk screening immediately upon arrival. The Veteran will be evaluated for appropriate level of care by a License Independent Practitioner (LIP). Any Veteran who presents to the ED with potentially suicidal or homicidal ideation should be contained in an area with direct continuous observation until disposition is made. A SBR will be completed by staff when a staff member is made aware of any episode by a Veteran of self-directed violent behavior that has not been previously documented in the Veteran’s CPRS that occurred within the previous 12 months. If the Veteran presents to the ED with current reports of suicidal ideation or other self-directed violence with intent and plan, the staff member will complete a SBR.

(5) Outpatient (OP): Veterans who present as not acutely suicidal may be managed on an outpatient basis. A SRA and a SPSP will be conducted at intervals determined by the Mental Health Provider.

(a) In order to identify Veterans at risk for suicide, a depression screen will be conducted on all new Veterans and annually for all established Veterans. If the depression screen is positive, a LIP must complete a SRA. A LIP is a MD, DO, Psychologist, LCSW, APN/NP, PA or other allied health care professionals who, by virtue of their educational and approved credentialing privileging and/or scope of practice have been determined by VANTHCS privileged to diagnose and treat mental illness.

(b) If the Suicide Risk Screening is positive, the Veteran must be referred to Mental Health Service (MHS) for a comprehensive SRA. The Veteran must be escorted to MHS immediately and under no circumstances will the Veteran be left alone during this hand-off process.

(c) Mental Health providers and/or LIPs must complete and document in CPRS a SRA. The SRA must include the following factors:

active and passive suicidal ideation.

suicide plans.

degree of current risk.

underlying disorder.

significant recent and past history with of self-directed

Violence.

identification of the most appropriate setting for level of care.

(d) Low or moderate: In the case of a Veteran where risk is determined to be low or moderate, the Veteran and his/her significant other will be provided contact instructions, including telephone number of how and who to contact in case of an exacerbation of suicidal ideation or self-directed violence.

(e) Category I PRF: All Veterans who have a PRF will receive an enhanced care plan. The enhanced care plan consists of four mental health appointments during the first month of the 90 days and one appointment per month the second and third month of the 90 day. At the end of 90 days the Veteran will be assessed to determine if the PRF needs to be continued for an additional 30 days or deactivated. If the PFR is continued an additional 30 days, the Mental Health Provider will schedule at a minimum one mental health appointment with the patient and will complete a SRA and SPSP.

Monitor Category I PRF: The SPC will monitor to ensure that Veterans who have a PRF are keeping their appointments. In the event of a no-show or missed appointment, the Veteran’s Provider will make a minimum of three attempts to contact the Veteran to reschedule the missed appointment. If the Provider or the SPC feel the Veteran might be in imminent danger or self-harm, the local police or sheriff's office will be contacted to request the initiation of a welfare check.

(6) Suicide Event: Any VANTHCS’ staff who becomes aware of any of the following self-directed violence events, such as a completed suicide, a suicide attempt or suicidal ideation with intent and plan requires that the employee immediately complete a SBR and modify the Veteran’s treatment plan. This report is a template in CPRS under the note title Suicide Behavior Report.

(a) Should a completed suicide or attempted suicide occur on station, the area will be secured with any evidence and VA Police notified.

(b) Staff debriefing assistance is available for staff troubled by a suicide of a Veteran through the Employee Assistance Program (EAP). For EAP assistance contact the Chief of Psychology.

(7) Veteran’s Crisis Line: All suicidal crisis calls will be handled through the Veteran's Crisis Line (VCL). The following procedure will be followed:

(a) When a Veteran calls VANTHCS and verbalizes suicidal ideation or is in a suicidal crisis, the call will be warmly transferred to the Veteran’s Crisis Line, (800) 273-8255 or extension 74950 if calling from within the medical center.

(b) Before transferring the call, the staff member must obtain the name, telephone number, last four of the Veteran's social security number, address and current physical location. The staff member transferring the Veteran to the VCL will explain to the Veteran that they are being transferred to the VCL to obtain help for them.

(c) A “warm transfer” means that the VANTHCS’ staff will transfer the Veteran the Veteran’s Crisis Line and give the hotline staff, the Veteran's name, telephone number, last four of the Veteran’s Social Security number, address and current physical location.

(d) The VANTHCS’ staff member will document the event in the Veteran’s CPRS and add the Veteran’s mental health provider and the SPC as cosigners to the CPRS note.

(e) The SPC will follow-up on the call per established protocol through the Veteran's Crisis Line and Medora.

(8) Self-Directed Violence (SDV) Classification System: For the purpose of documentation and reporting the following standardized nomenclature for suicide-related thoughts and behaviors will be utilized. The uniform definitions for Self-directed Violence Classicization System (SDVCS) was developed by the Centers for Disease Control and Prevention (CDC), Department of Veterans Affairs (VA) and Department of Defense (DOD). A Clinical Tool, using SDVCS has been developed by the Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center (VISN 19 MIRECC). Use of the SDVCS definitions for behavior that is self-directed and deliberately results in injury or the potential for injury to oneself will allow for specific recommendations for care at each determined point of classification, as well as, communication concerning risk levels and care interventions among VA providers.

(a) 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.

(b) Suicidal Ideation: Thoughts of engaging in suicide-related behavior.

(c) Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or potential for injury to oneself.

(d) Non-Suicidal Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.

(e) 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 on the available evidence.

(f) Suicide Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.

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

(h) Suicide: Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior.

(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 probable 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) Physical Injury: A (suspected) 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. In some cases an injury results from an insufficiency of vital elements, such as oxygen. Acute poisonings and toxic effects, including overdoses of substances and wrong substances given or taken in error are included, as are adverse effects and complications of therapeutic, surgical, and medical care. Psychological injury is excluded in this context.

(l) Interrupted Self-Directed Violence by Another: A person takes steps to injure self, but, is stopped by another person prior to fatal injury. The interruption may occur at any point.

(m) Interrupted Self-Directed Violence by Self: A person takes steps to injure self, but, is stopped by self-prior to fatal injury. This interruption may occur at any point.

(n) Fatal: Causing Death

4.

RESPONSIBILITIES:

a.

Chief of Staff is responsible for assuring compliance with this policy.

b.

Service Chiefs or Designees are responsible for ensuring employees receive training on the recognition, management and reporting of suicidal behavior/events.

c.

Suicide Prevention Coordinators (SPC) have the responsibility to facilitate implementation and maintenance of suicide prevention strategies within the medical center, the outpatient clinics and the CBOCs to help ensure that all appropriate measures are being taken to prevent suicide in the Veteran population. SPCs, in collaboration with care teams and service providers are charged with the following:

(1) Conduct reviews of all Suicidal Behavior Reports.

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

(3) Collect, trend and report data regarding suicidal events.

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

(5) Track and report the status of actions taken in response to suicidal events.

(6) Control the Category I Patient Record Flag as it relates to high risk for suicide. The SPC limits the use of this flag to Veterans who meet the criteria for placement on this list. The SPC reviews the PRF at the end of 90 days to determine if the Veteran continues to meet criteria for the flag.

(7) Participates in individual Root Cause Analysis (RCA) and aggregate reviews concerning Veterans who have attempted or completed a suicide.

(8) Participates in Environment of Care rounds to ensure compliance with safety standards developed by the National Center for Patient Safety.

(9) Establish relationships with local and state organizations to promote education and awareness of suicide prevention strategies.

(10) Develop partnerships with Transition and Care Management Coordinators, Patient Safety Managers (PSM), Health Care for Homeless Veterans (HCHV) Coordinators, local Vet Center staff, residential care team and local mental health teams. This partnership is to assure that Veterans are assessed and evaluated for suicide risk.

(11) After a Veteran is identified as High Risk, a SPC will monitor the Veteran who has received a PRF to ensure treatment compliance.

(12) The SPC is responsible for following up on all calls from the Veteran’s Crisis Line to ensure timely access to care for Veterans in crisis.

(13) The SPC is responsible for staff and Veteran education during Suicide Prevention Awareness Week.

(14) The SPC is responsible for educating and training efforts related to suicidal awareness, risk and prevention. This includes Operation SAVE for all new employees and training on the comprehensive care of a suicidal individual, SRA, SPSP, SBR and HR PRF. Education Service has uploaded Suicide Risk Management Training for Clinicians through Veteran Affairs Talent Management System for employees to complete within 90 days of hire.

d.

All employees are responsible for adhering to this policy.

5.

REFERENCES:

Under Secretary for Health's Information Letter, dated December 11, 2006: Joint Commission Comprehensive Accreditation Manual for Behavioral Health Care Standards 2012; VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, July 18, 2008. Self-Directed Violence (SDV) Classification System Clinical Tool, Centers for Disease Control and Prevention, Memorandum of Understanding between VANTHCS and the Veteran's Crisis Line.

6.

RESCISSION:

VANTHCS Memorandum No. 116A-01, April 15, 2014.

Jeffery L. Milligan

Director

Distribution: A