Zero Suicide Implementation


Jacqueline Ryan, MPH; Pavan Somusetty, MD; Han Liang, MD; Eli Pahl, LCSW, CADC III

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northwest

Background: Suicide claims more than 47,000 American lives each year, with each death leaving devastating and immeasurable impacts on surviving loved ones for decades or longer. Research shows that nationwide, almost half of those individuals had sought medical care in the last month before their death, often for other unrelated health care needs. In Oregon and Washington, suicide has risen to become the 8th leading cause of death. Kaiser Permanente Northwest’s (KPNW’s) Zero Suicide Initiative seeks to strengthen its health care system to prevent these tragic deaths by identifying its highest-risk members and by ensuring they receive timely and appropriate evidence-based interventions once identified.
Methods: The population included members of KPNW seen in Mental Health, Addiction Medicine, Primary Care, Pain Clinic, Obstetrics and Gynecology, and Pediatrics who answered a Patient Health Questionnaire (PHQ-9) used for screening and monitoring depression or those who otherwise indicated suicidal ideation directly to health care providers. We increased depression screening in Primary Care to all members and created consistent and reliable escalation pathways for anyone seen in the above departments who indicated a positive 9th question (the screening question for suicide) on the PHQ-9 by applying the Columbia-Suicide Severity Rating Scale (C-SSRS) during the visit before the patient left the office. The answers to this tool were collected as discrete data. Those who were seen outside of Mental Health and Addiction and scored a 3 or higher on the C-SSRS were provided a warm transfer to a behavioral health clinician (either in person or by phone) to collaboratively develop a safety plan intervention with rapid follow-up in a specialty mental health clinic. Those who were already being seen in a specialty mental health or addiction medicine clinic collaborated with their provider directly on the safety plan before leaving the office. Our outcome measures were: Depression screening rate, C-SSRS Utilization and Completion in Response to Elevated PHQ-9 9th item, and Suicide Incidence Rate in Mental Health and Addiction Medicine.
Results: Updated workflows in documentation for Pediatrics in April 2018 resulted in a significant increase in the depression screening rate from a baseline of 17.6% to 35.8% in September 2018. Universal screening for depression in the adult population began in August 2018, and we anticipate a similar increase in depression screening rates for adults in the coming months. Our baseline C-SSRS utilization rate (in response to a positive response to the 9th question on the PHQ-9) in December 2017 was 0.4% and by Q3 of 2018, this rate had increased to 60.1%. In May 2018, all mental health and addiction medicine clinicians were trained in the Stanley & Brown Safety Planning Intervention. Since this training, the Mental Health and Addiction Medicine Department has seen 2 calendar months of 0 suicides within the department.
Discussion: Tying the C-SSRS to the PHQ-9 workflows in departments that already use the PHQ-9 was a successful strategy in rolling out widespread suicide risk assessments. Collecting and reporting on measures and investing in training all mental health and addiction medicine clinicians in an evidence-based safety-planning intervention proved to reduce suicide incidence and helped to shift the culture at KPNW around suicide prevention. Our next steps include data collection for when safety plans are being used in response to an elevated C-SSRS score by capturing safety plans in the electronic medical record as discrete data, exploring the use of a risk calculator to further help determine those who would benefit from a C-SSRS even with a negative response to the PHQ-9, and engaging more departments in suicide risk identification, including the Emergency Medicine and Urgent Care.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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