Scott Radtke, LPC Amy Gunderson, CSW, LPC Gina Day, LPC, NCC 1 • Scott, Amy and Gina are employed at Catalpa Health, an outpatient mental health facility that serves children, adolescents and families in Appleton, Oshkosh and Waupaca, Wisconsin • They do not have any relevant financial, commercial or research affiliations that bias or influence the educational content of this presentation 2 1
• Objective 1: Learn about the framework for implementing Zero Suicide policies in your agency • Objective 2: Be able to employ strategies for assessing and documenting client risk • Objective 3: Understand specific therapeutic interventions for high risk clients 3 • Embedded in the National Strategy for Suicide Prevention • A priority of the National Action Alliance for Suicide Prevention • A project of the Suicide Prevention Resource Center • A focus on error reduction and safety in healthcare • A framework for systematic, clinical suicide prevention in behavioral health and healthcare systems • A set of best practices and tools including www.zerosuicide.com 4 2
• Suicide prevention is a core responsibility of healthcare • Focus on applying new knowledge about suicide and treating it directly • A systematic clinical approach in health systems, not “the heroic efforts of crisis staff and individual clinicians” From: To: Accepting suicide as inevitable Every suicide in a system is preventable Assigning blame Nuanced understanding: ambivalence, resilience, recovery Risk assessment and containment Collaborative safety, treatment, recovery Stand alone training and tools Overall systems and culture changes Specialty referral to niche staff Part of everyone’s job Standardized screening, assessment, risk stratification, and Individual clinician judgment & actions interventions Hospitalization during episodes of crisis Productive interactions throughout ongoing continuity of care “If we can save one life…” “How many deaths are acceptable?” 5 Zero Suicide Steering Committee and Sub-Committees • Lead and Improve • Utilize processes and policies to implement Zero Suicide throughout the agency • Develop ways to utilize data tracking and continue to assess effectiveness of our Zero Suicide approach • Train • Determine and plan for best training opportunities for clinical and non-clinical staff • Develop methods to assess and increase staff confidence and competencies around Zero Suicide 6 3
Zero Suicide Steering Committee and Sub-Committees (cont.) • Identify and Treat • Identify screening tools, methods, protocols and policies for agency-wide suicide assessment • Develop effective treatment planning, create process for following up with high risk clients, create “SMART” treatment goals and improve documentation and plan for clinical trainings • Engage and Transition • Develop processes to identify high risk clients, standardize safety planning, identify process for outreach of missed appointments, improve access for urgent client needs and find resources for families • Assist families with various points of transition in treatment 7 • Improving clinical competency • Risk assessment and management • Homicidal ideation • Non-suicidal self-injury • Suicidal ideation • Training for clinical staff • Columbia Suicide Severity Rating Scale • Assessment and management of suicide risk formulation • Management of homicidal and aggressive ideation/behaviors • DBT Trainings with Dr. Ursula Whiteside and Lane Pederson • CALM Training • Motivational interviewing • Philosophy/culture shift with language used by staff 8 4
• Communication is key • Invest in relationships (i.e. school staff, hospital staff, primary care physicians, coroners, police officers) in your community • County Child Death Review Teams • Band with other agencies to form coalitions • Discuss timely disclosures of deaths by suicide in order to mitigate the contingent effect • Work to end the stigma associated with suicidality and risk 9 • Investigate HIPAA harmonization options in your agency • HIPAA PRIVACY LAW 45 CFR § 164.512(j)(1)(i) “USES AND DISCLOSURES TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY A covered entity may, consistent with applicable law and standards of ethical conduct, use or disclose protected health information, if the covered entity, in good faith, believes the use or disclosure: (i) (A) Is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; and (B) Is to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat” 10 5
• Use of C-SSRS and C-SSRS pediatric version to determine clients’ risk for suicide and/or self-harm • Use of ACORN outcome survey at the start of each appointment • Training Call Center Staff to assess risk via phone and triage clients when needed • Additional information in therapy progress note templates to include assessment questions and identify risk status/risk state/coping resources/potential triggers/plan to address risk • Offering of QPR trainings in the schools 11 12 6
13 • Updating templates for written safety plans • Creating these collaboratively with clients/families and sharing them with social supports, school staff and primary care physicians • Thinking creatively to improve client accountability and comfort • Communicating client needs with parents/caregivers in the session and afterwards 14 7
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• Firearms • Therapists should be more direct with asking families about weapons in the home • Follow up with divorced/separated parents who are not present at the appointment • Give out gun locks to families if available • Medications • Offer prescription medication drop-offs when a client does not finish a medication • Identify alternative drug drop-off locations other than police stations • Offer staff trainings on medication lethality • Remember over-the counter medications 17 • Methods for following up with clients who have been identified with suicide risk during their most recent appointment • Can be done in the form of “Caring Calls,” “Caring Letters” or “Caring Messages” • Caring Calls and Caring Letters should be sent within 3 business days of the client’s last appointment to assess safety, provide recommendations and triage care if needed • Caring Contact Team was established to ensure these are completed if treating clinician is unavailable • Caring Messages can be given to client at the conclusion of their appointment 18 9
• Reason for call is documented in the client’s chart as “Suicidal Ideation” • Provider completes the following documentation information, which was created as a template: “Caring contact was made to the family to check in about safety of client. Parent/caregiver reported safety plan was adequate/required further triage or resources/was unable to be reached/***. Parent/caregiver indicated confidence in/concern with being able to maintain client’s safety until next session. Plan was made to continue with safety plan and attend follow up session on (date)/modify safety plan to ***/schedule an additional session on (date)/consider a higher level of care, specifically hospitalization, welfare check, or ***.” 19 • Letter title is documented as “Caring Contact” “Dear Client, I wanted to get in touch with you since I have been unable to reach you via phone since our last appointment. Please call me at your earliest convenience to let me know how you are doing and continue to use your safety plan in the meantime. If you are in need of immediate support, please go to the Emergency Room or call our Call Center at (920)750- 7000 or the *** County Crisis hotline at (***)***-****. I am looking forward to seeing you for our next appointment on ***!” 20 10
21 You’ve got this Thank you for sharing with me today I look forward to seeing you again It was good to see you today I have hope for you What you’re going through is tough, and I am here for you Even if it seems like no one cares, I care Right now, things may not be great, but you’ve come so far It’s okay to not be okay. I have hope for you for the future There’s someone out there that’s feeling similar to the way you feel You’re an amazing fighter You’ve come so far You are great Even though it might seem hard and difficult, you will get through this. It just takes time One step at a time, you’ll overcome this Happiness will come one day This feeling won’t last forever You’re amazing, be yourself It’s okay to feel this way 22 11
• Set of best practice guidelines and treatment modules for therapists to provide more focused and intensive care (ideally at least 6 weekly sessions) to clients at high risk for suicide • Treatment module topics are based on Dialectical Behavioral Therapy principles and include: relaxation, emotional regulation, distress tolerance and communication with social supports • Therapists can use workbooks developed for this purpose or use their own materials to teach these skills • Team approach involves designating that client is on the Care Pathway so this can be seen by other staff and communicating this information and client’s written safety plan to primary care physician and school staff 23 • Discuss obstacles from each role/perspective • How Zero Suicide has made a difference in our roles • Write down 3 things you could implement in your role to work to prevent suicide with your clientele 24 12
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