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Suicide Prevention in Primary Care

eSolutions: Suicide Prevention in Primary Care

Featured Article: Primary Care: A Crucial Setting for Suicide Prevention
Profile: New York Health Center Taps Into the Saving Power of EHRs
Quick Tips: Suicide Warning Signs
CIHS Webinars
Hot Topics

Primary Care:  A Crucial Setting for Suicide Prevention

Jerry Reed, PhD, MSW, Director, Suicide Prevention Resource Center

Up to 45% of individuals who die by suicide have visited their primary care physician within a month of their death; additional research suggests that up to 67% of those who attempt suicide receive medical attention as a result of their attempt. Given these statistics, primary care has enormous potential to prevent suicides and connect people to needed specialty care — especially when they collaborate or formally partner with behavioral healthcare providers.

By integrating primary and behavioral care, healthcare professionals can poise their practices for focused and effective suicide prevention efforts. Integrated healthcare providers tend to have strong relationships with their communities, helping them to combat social views around suicide that dissuade people from seeking the treatments and supports that could prevent tragic results. They communicate and collaborate on individuals’ care regularly and share health information electronically, enabling them to identify individuals at risk of suicide who are not actively seeking mental health treatment and to provide the care so desperately needed. Ultimately, through true collaboration, these integrated healthcare providers can reduce overall suicide rates.

Primary care physicians are increasingly asked to screen for a variety of health conditions, but often lack the capacity to take these screenings on or know where to make appropriate referrals for those who screen positive. However, there are brief screening tools for suicide and other mental health issues that people can complete while in waiting areas that providers then review to identifying in advance those who may be at-risk and need additional time. These are easily implemented and operationalized. The burden needn’t fall directly on the shoulders of physicians either, as nurse educators, nurse practitioners, or other health professionals can take on the task of screening individuals for depression, suicide, and mental and substance use disorders.

Furthermore, there are tools available for practitioners looking to enhance their suicide screening efforts that can help them establish protocols to identify those at risk and needing referrals to appropriate care. For example, the Suicide Prevention Toolkit for Rural Primary Care is a free resource containing tools and protocols for the whole practice. Implementing such protocols reduces the burden on primary care practices and increases the numbers of people identified and helped. Collaboration with behavioral health providers helps establish a climate of prevention, and reduces the anxiety and burden of dealing with individuals requiring intervention. 

Recognizing the need to reach beyond the traditional boundaries of behavioral healthcare to address suicide, the U.S. Surgeon General and the National Action Alliance for Suicide Prevention called for new efforts to establish suicide prevention standards and practices in and across key health care system settings such as primary care, in the revised National Strategy for Suicide Prevention, released  in 2012.  

Jerry Reed, PhD, MSW, is the Director of the Suicide Prevention Resource Center, the nation’s only federally supported resource center devoted to advancing the National Strategy for Suicide Prevention. We provide technical assistance, training, and materials to increase the knowledge and expertise of suicide prevention practitioners and other professionals serving people at risk for suicide. We also promote collaboration among a variety of organizations that play a role in developing the field of suicide prevention.


FQHC Profile

New York Health Center Taps Into EHRs’ Role in Lifesaving

Neil Calman, MD, President and CEO, and Virna Little, PsyD, LCSW-r, Senior Vice President, Psychosocial Services and Community Affairs — SAP Institute for Family Health, New York, NY

Traditionally, the responsibility of assessing suicide risk has mainly fallen to primary care professionals, as they often actively treat people who are suicidal but not engaged in mental health treatment. Recent research shows that 25-60% of people contemplating suicide seek attention for a medical problem in the weeks before death, and yet as many as 81% do not seek prior psychiatric help. Such evidence speaks to the need for systems to help identify and monitor individuals at risk for suicide in primary care settings.

Electronic health records facilitate immediate feedback to healthcare providers and offer ways to identify and track potentially suicidal patients. Using EHRs, with the involvement of primary care providers, in suicide assessment and prevention may significantly help identify suicidal patients who are not actively seeking mental health treatment and ultimately reduce overall suicide rates. Understanding the major effect that training and EHR decision support can have on suicidality, the Institute for Family Health, a not-for-profit community health center network located in New York, launched a two-prong approach striving for a zero suicide rate in the populations it serves.

The Institute’s senior leadership understood that training staff on suicide prevention and awareness is crucial to eliminating completed suicides in its patient population. Partnering with the Mental Health Association of Ulster County and Dr. Max Banilivy, the Institute set upon a mission to train its entire staff using the evidence-based models SAFETALK and ASIST. In 2008, the Institute implemented a policy mandating suicide prevention training for every employee. All staff, regardless of discipline or position, must participate in at least one of the trainings: behavioral health staff participate in the two-day ASIST training and all other staff attend the 3-hour SAFETALK training. The Institute has trained over 700 of its 900 staff members, making this initiative one of the largest employer suicide prevention initiatives in New York. As a training center for family practice and mental health clinicians, the Institute’s mandate ensures that over 50 mental health interns and family practice residents are trained each year.

The Institute's second initiative was implementation of the EHR system Epic (Epic Systems, Verona, Wisconsin) 10 years ago for the identification and assessment of patients at risk for suicide. While the Institute implemented Epic, it simultaneously launched a depression identification and treatment program, making it the first organization to build the PHQ9 depression screening tool into their EHR, scoring it as a lab value. When the PHQ-9 score is a 10 or above, it is added as an abnormal lab value in the EHR, which then alerts providers to the patient’s potential risk. Many organizations only flag scores over 10 as an alert; the Institute took it one step further, adding the additional indicator of using a decimal point score for how a patient answers on question 9 (Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?), which better alerts staff to the patient’s thoughts of suicide. While electronic health technology and the use of the PHQ-9 has advanced since that time, the Institute maintains one of the country's highest screening rates at almost 90%.

Now, the Institute requires that all patients who respond positively to the PHQ-9 suicide screening question have “suicide risk” put on their problem list, which means it is visible to all providers who see the patient regardless of discipline, and it is “blown in” to each provider’s note, automatically bringing immediate attention to the patient's risk for suicide. Staff are required to ask the patient if they are at risk. Then, they must develop and review the safety plan and, if necessary, seek mental health support if they are not a mental health provider.

A safety plan has been built into the EHR that is designed to be completed concurrently with the patient and can be printed individually or as part of an after-visit summary for the patient. As part of a comprehensive suicide prevention program, the Institute developed policies that require direct care staff of any discipline to address suicidality during all interactions.

The Institute also pioneered several decision support tools to alert providers of a patient at risk of suicide. An “FYI” alert is placed in the patient’s chart that pops up to notify all providers that the patient needs to be assessed for risk as they open the encounter. The ability to view the FYI alert gives providers immediate information on how to access the patient’s safety plan and information regarding the patient’s suicidality in order to review it with the patient and further assess risk.

The Institute can run reports for patients with “suicide risk” on their problem lists that have not accessed the organization in 30, 60, or 90 days, prompting staff to review the patients’ records and conduct outreach calls or visits. The Institute also utilizes two electronic portals?a physician portal and patient care portal. The patient care portal, or “MyChart,” allows patients to view their health records, obtain accurate health related information, and communicate with their providers. The Institute has recently built the PHQ-9 into the MyChart portal so patients can complete the tool electronically while in the community. In addition, the ability to communicate with their provider through secure electronic mail helps patients because they can reach out to someone with whom they have a relationship for help and support. The physician portal, “InstituteLink,” provides access to patients’ records. The community providers' ability to see a patient’s problem list alerts them to a patient’s potential suicide risk and gives them access to the safety plan, allowing them to review and update the plan with the patient thereby reducing the patient's risk. This increases the opportunities for assessment, risk reduction, and care coordination as community organizations can communicate with the patients’ health and mental health providers at the Institute, creating a true care network for the patient.

The EHRs can play a significant role in identifying patients in community health settings, a common difficulty. Including risk in problem lists, in addition to decision support tools, can dramatically improve the likelihood of assessment for an at-risk patient. However, without proper training, providers in community health settings will feel unprepared to ask patients about suicidality ? and we will continue to see the high rates of completed suicides for patients known to primary care. Community health organizations can significantly impact suicide rates by adopting a model that incorporates both the systematic training of providers and the identification and monitoring of at-risk patients through their electronic health records.

For more information on the Institute for Family Health, visit www.institute2000.org.


Quick Tips

Suicide Warning Signs

The number one thing that any healthcare professional can do to prevent suicide is to know the warnings signs. All integrated care staff may find the following list of warning signs useful in identifying a person who by be at acute (immediate, severe) risk of taking their own life.

A person at acute risk of suicidal behavior will often show warning signs such as:

  • Threatening to hurt or kill oneself, or talking of wanting to hurt or kill him/herself
  •  Looking for ways to kill oneself by seeking access to firearms, available pills, or other means
  • Talking or writing about death, dying or suicide, when these actions are out of the ordinary

A person may also shows addition signs such as:

  • Increased alcohol or drug use
  • No reason for living; no sense of purpose in life
  • Anxiety, agitation, unable to sleep, or sleeping all the time
  • Feeling trapped- like there’s no way out
  • Hopelessness
  • Withdrawal from friends, family, and society
  • Rage, uncontrolled anger, seeking revenge
  • Acting reckless or engaging in risky activities, seemingly without thinking
  • Dramatic mood changes, including sudden elevation in mood

Featured Resource

The Suicide Prevention Toolkit for Rural Primary Care is a free resource containing tools and protocols for the whole practice. Implementing such protocols reduces the burden on primary care practices and increases the numbers of people identified and helped. Collaboration with behavioral health providers helps establish a climate of prevention, and reduces the anxiety and burden of dealing with individuals requiring intervention. 

CIHS Webinars

CIHS will host a webinar on preventing suicide in integrated healthcare settings in late March. Stay tuned for details.

Missed past CIHS webinars? You can view these webinars at www.integration.samhsa.gov/about-us/webinars


Hot Topics 

CMS Recommends Health Home Quality Measures to State Medicaid Directors
On January 15, the Centers for Medicare and Medicaid Services sent a letter to state Medicaid directors with information on a newly recommended set of healthcare quality measures to assess health home service delivery. The eight recommendations focus on measuring overall health and mental health services. Once published as a final rule, Medicaid health homes will be required to adopt these quality measures.

New Health Literacy Tool for Primary Care
Health Literacy Universal Precautions Toolkit, a new resource commissioned by the Agency for Healthcare Research and Quality, offers primary care settings a way to assess their services for health literacy considerations, raise staff awareness, and work on specific issues.

Utah’s Plan to Go Smoke Free
Communities Putting Prevention to Work, an initiative that supports states and communities to tackle obesity and tobacco use, enabled the Utah Tobacco Prevention and Control Program to engage partners to ban tobacco use in all publically funded behavioral health facilities by 2013 and incorporate cessation activities into treatment. 

Million Hearts Releases Resources in Spanish
Million Hearts, a national initiative to prevent one million heart attacks and strokes by 2017, released Spanish-speaking resources on heart health, including a fact sheet, booklet on sodium intake reduction, and new website.

Smoking Rate 70% Higher in People with Mental Illness than General Population
According to a new report from the Centers for Disease Control and Prevention, in collaboration with SAMHSA, 36% of adults with a mental illness smoke cigarettes, compared to only 21% of adults who do not have a mental illness- making the smoking rate 70% higher among people with mental illnesses.

California Quantifies Dual Eligible Spending and Services
California is pursuing policies to support quality care, including home- and community-based services, while managing expenditures. Highlighting the cost of this care, the California Medicaid Research Institute published Medi-Cal Beneficiaries Who Use Long-Term Services and Supports: Profiles of Utilization and Spending in Eight Dual Eligible Integration Counties, 2008.

Apply for Loan Repayment from NHSC
The 2013 National Health Service Corp (NHSC) Loan Repayment Program application cycle is now open. The program offers primary care medical, dental, and mental and behavioral health providers the opportunity to have their student loans repaid while serving in communities with limited access to care.

Call Our Helpline: 202.684.7457

eSolutions: Suicide Prevention in Primary Care

Featured Article: Primary Care: A Crucial Setting for Suicide Prevention
Profile: New York Health Center Taps Into the Saving Power of EHRs
Quick Tips: Suicide Warning Signs
CIHS Webinars
Hot Topics

Primary Care:  A Crucial Setting for Suicide Prevention

Jerry Reed, PhD, MSW, Director, Suicide Prevention Resource Center

Up to 45% of individuals who die by suicide have visited their primary care physician within a month of their death; additional research suggests that up to 67% of those who attempt suicide receive medical attention as a result of their attempt. Given these statistics, primary care has enormous potential to prevent suicides and connect people to needed specialty care — especially when they collaborate or formally partner with behavioral healthcare providers.

By integrating primary and behavioral care, healthcare professionals can poise their practices for focused and effective suicide prevention efforts. Integrated healthcare providers tend to have strong relationships with their communities, helping them to combat social views around suicide that dissuade people from seeking the treatments and supports that could prevent tragic results. They communicate and collaborate on individuals’ care regularly and share health information electronically, enabling them to identify individuals at risk of suicide who are not actively seeking mental health treatment and to provide the care so desperately needed. Ultimately, through true collaboration, these integrated healthcare providers can reduce overall suicide rates.

Primary care physicians are increasingly asked to screen for a variety of health conditions, but often lack the capacity to take these screenings on or know where to make appropriate referrals for those who screen positive. However, there are brief screening tools for suicide and other mental health issues that people can complete while in waiting areas that providers then review to identifying in advance those who may be at-risk and need additional time. These are easily implemented and operationalized. The burden needn’t fall directly on the shoulders of physicians either, as nurse educators, nurse practitioners, or other health professionals can take on the task of screening individuals for depression, suicide, and mental and substance use disorders.

Furthermore, there are tools available for practitioners looking to enhance their suicide screening efforts that can help them establish protocols to identify those at risk and needing referrals to appropriate care. For example, the Suicide Prevention Toolkit for Rural Primary Care is a free resource containing tools and protocols for the whole practice. Implementing such protocols reduces the burden on primary care practices and increases the numbers of people identified and helped. Collaboration with behavioral health providers helps establish a climate of prevention, and reduces the anxiety and burden of dealing with individuals requiring intervention. 

Recognizing the need to reach beyond the traditional boundaries of behavioral healthcare to address suicide, the U.S. Surgeon General and the National Action Alliance for Suicide Prevention called for new efforts to establish suicide prevention standards and practices in and across key health care system settings such as primary care, in the revised National Strategy for Suicide Prevention, released  in 2012.  

Jerry Reed, PhD, MSW, is the Director of the Suicide Prevention Resource Center, the nation’s only federally supported resource center devoted to advancing the National Strategy for Suicide Prevention. We provide technical assistance, training, and materials to increase the knowledge and expertise of suicide prevention practitioners and other professionals serving people at risk for suicide. We also promote collaboration among a variety of organizations that play a role in developing the field of suicide prevention.


FQHC Profile

New York Health Center Taps Into EHRs’ Role in Lifesaving

Neil Calman, MD, President and CEO, and Virna Little, PsyD, LCSW-r, Senior Vice President, Psychosocial Services and Community Affairs — SAP Institute for Family Health, New York, NY

Traditionally, the responsibility of assessing suicide risk has mainly fallen to primary care professionals, as they often actively treat people who are suicidal but not engaged in mental health treatment. Recent research shows that 25-60% of people contemplating suicide seek attention for a medical problem in the weeks before death, and yet as many as 81% do not seek prior psychiatric help. Such evidence speaks to the need for systems to help identify and monitor individuals at risk for suicide in primary care settings.

Electronic health records facilitate immediate feedback to healthcare providers and offer ways to identify and track potentially suicidal patients. Using EHRs, with the involvement of primary care providers, in suicide assessment and prevention may significantly help identify suicidal patients who are not actively seeking mental health treatment and ultimately reduce overall suicide rates. Understanding the major effect that training and EHR decision support can have on suicidality, the Institute for Family Health, a not-for-profit community health center network located in New York, launched a two-prong approach striving for a zero suicide rate in the populations it serves.

The Institute’s senior leadership understood that training staff on suicide prevention and awareness is crucial to eliminating completed suicides in its patient population. Partnering with the Mental Health Association of Ulster County and Dr. Max Banilivy, the Institute set upon a mission to train its entire staff using the evidence-based models SAFETALK and ASIST. In 2008, the Institute implemented a policy mandating suicide prevention training for every employee. All staff, regardless of discipline or position, must participate in at least one of the trainings: behavioral health staff participate in the two-day ASIST training and all other staff attend the 3-hour SAFETALK training. The Institute has trained over 700 of its 900 staff members, making this initiative one of the largest employer suicide prevention initiatives in New York. As a training center for family practice and mental health clinicians, the Institute’s mandate ensures that over 50 mental health interns and family practice residents are trained each year.

The Institute's second initiative was implementation of the EHR system Epic (Epic Systems, Verona, Wisconsin) 10 years ago for the identification and assessment of patients at risk for suicide. While the Institute implemented Epic, it simultaneously launched a depression identification and treatment program, making it the first organization to build the PHQ9 depression screening tool into their EHR, scoring it as a lab value. When the PHQ-9 score is a 10 or above, it is added as an abnormal lab value in the EHR, which then alerts providers to the patient’s potential risk. Many organizations only flag scores over 10 as an alert; the Institute took it one step further, adding the additional indicator of using a decimal point score for how a patient answers on question 9 (Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?), which better alerts staff to the patient’s thoughts of suicide. While electronic health technology and the use of the PHQ-9 has advanced since that time, the Institute maintains one of the country's highest screening rates at almost 90%.

Now, the Institute requires that all patients who respond positively to the PHQ-9 suicide screening question have “suicide risk” put on their problem list, which means it is visible to all providers who see the patient regardless of discipline, and it is “blown in” to each provider’s note, automatically bringing immediate attention to the patient's risk for suicide. Staff are required to ask the patient if they are at risk. Then, they must develop and review the safety plan and, if necessary, seek mental health support if they are not a mental health provider.

A safety plan has been built into the EHR that is designed to be completed concurrently with the patient and can be printed individually or as part of an after-visit summary for the patient. As part of a comprehensive suicide prevention program, the Institute developed policies that require direct care staff of any discipline to address suicidality during all interactions.

The Institute also pioneered several decision support tools to alert providers of a patient at risk of suicide. An “FYI” alert is placed in the patient’s chart that pops up to notify all providers that the patient needs to be assessed for risk as they open the encounter. The ability to view the FYI alert gives providers immediate information on how to access the patient’s safety plan and information regarding the patient’s suicidality in order to review it with the patient and further assess risk.

The Institute can run reports for patients with “suicide risk” on their problem lists that have not accessed the organization in 30, 60, or 90 days, prompting staff to review the patients’ records and conduct outreach calls or visits. The Institute also utilizes two electronic portals?a physician portal and patient care portal. The patient care portal, or “MyChart,” allows patients to view their health records, obtain accurate health related information, and communicate with their providers. The Institute has recently built the PHQ-9 into the MyChart portal so patients can complete the tool electronically while in the community. In addition, the ability to communicate with their provider through secure electronic mail helps patients because they can reach out to someone with whom they have a relationship for help and support. The physician portal, “InstituteLink,” provides access to patients’ records. The community providers' ability to see a patient’s problem list alerts them to a patient’s potential suicide risk and gives them access to the safety plan, allowing them to review and update the plan with the patient thereby reducing the patient's risk. This increases the opportunities for assessment, risk reduction, and care coordination as community organizations can communicate with the patients’ health and mental health providers at the Institute, creating a true care network for the patient.

The EHRs can play a significant role in identifying patients in community health settings, a common difficulty. Including risk in problem lists, in addition to decision support tools, can dramatically improve the likelihood of assessment for an at-risk patient. However, without proper training, providers in community health settings will feel unprepared to ask patients about suicidality ? and we will continue to see the high rates of completed suicides for patients known to primary care. Community health organizations can significantly impact suicide rates by adopting a model that incorporates both the systematic training of providers and the identification and monitoring of at-risk patients through their electronic health records.

For more information on the Institute for Family Health, visit www.institute2000.org.


Quick Tips

Suicide Warning Signs

The number one thing that any healthcare professional can do to prevent suicide is to know the warnings signs. All integrated care staff may find the following list of warning signs useful in identifying a person who by be at acute (immediate, severe) risk of taking their own life.

A person at acute risk of suicidal behavior will often show warning signs such as:

  • Threatening to hurt or kill oneself, or talking of wanting to hurt or kill him/herself
  •  Looking for ways to kill oneself by seeking access to firearms, available pills, or other means
  • Talking or writing about death, dying or suicide, when these actions are out of the ordinary

A person may also shows addition signs such as:

  • Increased alcohol or drug use
  • No reason for living; no sense of purpose in life
  • Anxiety, agitation, unable to sleep, or sleeping all the time
  • Feeling trapped- like there’s no way out
  • Hopelessness
  • Withdrawal from friends, family, and society
  • Rage, uncontrolled anger, seeking revenge
  • Acting reckless or engaging in risky activities, seemingly without thinking
  • Dramatic mood changes, including sudden elevation in mood

Featured Resource

The Suicide Prevention Toolkit for Rural Primary Care is a free resource containing tools and protocols for the whole practice. Implementing such protocols reduces the burden on primary care practices and increases the numbers of people identified and helped. Collaboration with behavioral health providers helps establish a climate of prevention, and reduces the anxiety and burden of dealing with individuals requiring intervention. 

CIHS Webinars

CIHS will host a webinar on preventing suicide in integrated healthcare settings in late March. Stay tuned for details.

Missed past CIHS webinars? You can view these webinars at www.integration.samhsa.gov/about-us/webinars


Hot Topics 

CMS Recommends Health Home Quality Measures to State Medicaid Directors
On January 15, the Centers for Medicare and Medicaid Services sent a letter to state Medicaid directors with information on a newly recommended set of healthcare quality measures to assess health home service delivery. The eight recommendations focus on measuring overall health and mental health services. Once published as a final rule, Medicaid health homes will be required to adopt these quality measures.

New Health Literacy Tool for Primary Care
Health Literacy Universal Precautions Toolkit, a new resource commissioned by the Agency for Healthcare Research and Quality, offers primary care settings a way to assess their services for health literacy considerations, raise staff awareness, and work on specific issues.

Utah’s Plan to Go Smoke Free
Communities Putting Prevention to Work, an initiative that supports states and communities to tackle obesity and tobacco use, enabled the Utah Tobacco Prevention and Control Program to engage partners to ban tobacco use in all publically funded behavioral health facilities by 2013 and incorporate cessation activities into treatment. 

Million Hearts Releases Resources in Spanish
Million Hearts, a national initiative to prevent one million heart attacks and strokes by 2017, released Spanish-speaking resources on heart health, including a fact sheet, booklet on sodium intake reduction, and new website.

Smoking Rate 70% Higher in People with Mental Illness than General Population
According to a new report from the Centers for Disease Control and Prevention, in collaboration with SAMHSA, 36% of adults with a mental illness smoke cigarettes, compared to only 21% of adults who do not have a mental illness- making the smoking rate 70% higher among people with mental illnesses.

California Quantifies Dual Eligible Spending and Services
California is pursuing policies to support quality care, including home- and community-based services, while managing expenditures. Highlighting the cost of this care, the California Medicaid Research Institute published Medi-Cal Beneficiaries Who Use Long-Term Services and Supports: Profiles of Utilization and Spending in Eight Dual Eligible Integration Counties, 2008.

Apply for Loan Repayment from NHSC
The 2013 National Health Service Corp (NHSC) Loan Repayment Program application cycle is now open. The program offers primary care medical, dental, and mental and behavioral health providers the opportunity to have their student loans repaid while serving in communities with limited access to care.

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