Suicide Preventionin Health Care Settings & Communities

NAMI-NC Conference: Connecting Two Worlds: The Journey to WellnessIntegrating Physical and Behavioral Health Care

October 18, 2014

Jane Ann Miller, MPH, NC Division of Public HealthSusan E. Robinson, M.Ed., NC Division of MHDDSAS

Dedication

To those:

who have lost their lives by suicide,

who struggle with thoughts of suicide,

who have made an attempt on their lives,

caring for someone who struggles,

left behind after a death by suicide,

in recovery, and

To all those who work tirelessly to prevent suicide and suicide attempts in our nation.

We believe that we can and we will make a difference.

Common Understanding

• Suicide is best understood as a very complex human behavior, with no single determining cause.

• Suicide is a cause of death.• Suicide is preventable.• Future deaths are avoidable. • Impacts lives• Intervention and support is effective

Goals for today:

• Understand data supporting prevention• Learn about suicide prevention programs • Gain knowledge about state & national resources

Suicide and Self-Inflicted Injury in North Carolina

Data Sources: Suicide and Self-Inflicted Injury

• North Carolina Violent Death Reporting System (NC-VDRS)• Death Certificate• Law Enforcement Reports• Medical Examiner

• Hospital Discharge

• Emergency Department Admissions • NC-DETECT

Suicide Deaths, Hospitalizations and ED visits

102.1

6.2

22.9

67.3

91.6

129.5

0

20

40

60

80

100

120

140

Male Female

Cru

de

Rat

e p

er 1

00,0

00

Suicides Hospitalizations ED Visits

Rate of Suicides (2009-2011),Self-Inflicted Injury Hospitalizations (2009-2011) and Self-Inflicted

Injury ED Visits (2009-2012)for Ages 10 or Older in North Carolina by Gender

Suicide Deaths, Hospitalizations and ED visits

Rate of Suicides (2009-2011),Self-Inflicted Injury Hospitalizations (2009-2011) and Self-Inflicted

Injury ED Visits (2009-2012) for Ages 10 or Older in North Carolina by Age

0

30

60

90

120

150

180

210

240

10-1

415

-19

20-2

425

-34

35-4

445

-54

55-6

465

-74

75-8

4

85 +

Age Group (Years)

Cru

de

Rat

e p

er 1

00,0

00

Suicides

Hospitalizations

ED Visits

Suicide Deaths, Hospitalizations and ED visits

Male Rate of Suicides (2009-2011), Self-Inflicted Injury Hospitalizations (2009-2011) and Self-Inflicted Injury ED Visits

(2009-2012) for Ages 10 or Older in North Carolina by Age

0

50

100

150

200

250

Age Group (Years)

Cru

de R

ate

per

100,0

00 Suicides

HospitalizationsEmergency Visits

Suicide Deaths, Hospitalizations and ED visits

Female Rate of Suicides (2009-2011), Self-Inflicted Injury Hospitalizations (2009-2011) and Self-Inflicted Injury ED Visits

(2009-2012) for Ages 10 or Older in North Carolina by Age

0.0

50.0

100.0

150.0

200.0

250.0

300.0

Age Group (Years)

Cru

de R

ate

per

100,0

00

SuicidesHospitalizationsEmergency Visits

Map of Suicide Rates for Age 10 or Older by North Carolina County of Residence (2009-2011)

Map of Self-inflicted Injury Hospitalization Rates for Age 10 or Older by North Carolina County of Residence (2009-2011)

Map of Self-inflicted Injury ED Visit Rates for Age 10 or Older by North Carolina County of Residence (2009-2011)

Hospitalization and ED post-discharge risk

From Inpatient Settings

• 55% of post-inpatient discharge suicides die within first week (Brinkley et al. 2013)

From ED’s

Experience and research indicate people are still at risk after discharge particularly in the following 30 days.

• Over 1/3 re-attempt or die by suicide within 18 months post discharge(Beautrais, 2003)

• Studies suggest 50% -70% of suicide attempters fail to attend treatment post-discharge

Hospital Evidence Based Suicide Prevention Programs

• Emergency Room Intervention for Adolescent Females http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=33

• Emergency Department Means Restriction Educationtarget age 6-19 year olds

http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=15

• Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT)target age 55+

http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=257

Programs cross listed in the Suicide Prevention Resource Center’s (SPRC) Best Practices Registry http://www.sprc.org/

and the National Registry of Evidence-based Programs and Practices (NREPP) http://www.nrepp.samhsa.gov/

Hospital Suicide Prevention Programs/ Adherence to Standards

• "Is Your Patient Suicidal?" Emergency Department Poster and Clinical Guidehttp://www.sprc.org/bpr/section-III/your-patient-suicidal-emergency-department-poster-and-clinical-guide

• At-Risk in the EDone hour simulation training with avatars

http://www.sprc.org/bpr/section-III/risk-ed

• Question, Persuade, Refer (QPR) for Nurses3-6 hour on-line training

http://www.sprc.org/bpr/section-III/question-persuade-refer-qpr-nurses

• Recognizing and Responding to Suicide Risk in Primary Care One hour training

http://www.sprc.org/bpr/section-III/recognizing-and-responding-suicide-risk-primary-care-rrsr%E2%80%94pc

----------------------------------------------------------------------------------Suicide Prevention Toolkit for Rural Primary Care

http://www.sprc.org/for-providers/primary-care-tool-kit?sid=37583

Approaches to Engage Discharged Patients

• Follow-up calls, emails, postcards, texts

• Mobile Appso ReliefLink: monitor mood, suicidal thoughts, medication and appointment reminders,

safety plan, link to crisis serviceso MY3: three personal support contacts, direct connection to the National Lifeline

o mypsycho reachz

Crisis Services Continuum

Prevention

Early Intervention

Response

Stabilization

Mobile Crisis Team

CIT Partnership EMS Partnership

24/7 Crisis Walk-In Clinic

Hospital Emergency Dept.

Non-Hospital

23 hour Observation

Facility Based Crisis Non-hospital Detox

Hospital Units Community (including 3-way beds) State Psychiatric & ADATC

LME/MCO Care CoordinationCritical Time Intervention

Transition Supports

Psychiatric Advance Directives

WRAP

Person Centered Crisis Planning

Family & Community Support

Peer Support & Respite Services

Same Day Access Program

Outpatient Provider

LME-MCO Access Center

Primary Care Physician

MH First Aid

The Crisis Solutions Coalition Priorities• Fund, define, and monitor 24/7 Walk-in Crisis Centers as alternatives to

divert unnecessary ED visits AND as jail diversion sites for CIT officers• Provide training and support for all involved system partners – 911

responders, EDs, Providers, Consumers and Families• Re-work Mobile Crisis Teams• Fund the WHOLE service continuum -- Peer Support, Case

management, Jail in-reach, EMS diversion, etc.• More inpatient beds are needed• Utilize our collective data• Treat the whole person – integrated care• Emergency Departments should still have a role and be prepared to do

so• Focus on prevention strategies like Psychiatric Advance Directives and

MH First Aid

The Crisis Solutions Initiative

… building a crisis services continuum to match a continuum of crisis intervention

needs

For more info: Crystal FarrowCrisis Solutions Initiative Project Manager

http://crisissolutionsnc.org/

NC DIVISION OF MH/DD/SAS

Prevention in North CarolinaFor each of us as individuals –

NC Suicide Prevention Lifeline 1-800-273-8255 Its Ok To Ask” & chat lines Text for Teens: NAMI in partnership with MCOs (7 county

pilot) NC Youth MOVE, NAMI on Campus, Family to Family & Peer

Supports Evidenced based and informed services and supports Preventive health care

For family members –

LME/MCO Crisis Lines & Mobile Crisis Services Support Groups: Prevention & Postvention Outreach & support – consumer, youth & family

organizations Web sites: LME/MCO , state and national resources Evidenced based and informed services and supports

Prevention in North CarolinaFor communities at large –

Gatekeeper Trainings Learn signs & symptoms & ways to get help needed

Curricula Programs for Schools and Professional Groups• Training and Support through SAMHSA: Garrett Lee

Smith• Mental Health First Aid Training• Parents and Teachers as Allies

Prevention Coalitions and Community Collaboratives Parent Resource Centers Positive Parenting Programs Pro-social youth activities & leadership development Supports for those touched by suicide Trauma informed community engagement – “it takes a

village” Outreach to high risk groups – e.g. military, veterans &

Guard Public – private partnerships – faith, businesses, EAPs,

SROs, CITs, higher education

National & State Plans

• Everyone has a role in preventing suicides. – promote wellness– increase protective factors– reduce risk – promote effective treatment and recovery.

DHHS – public health and behavioral health work together• Promote public dialogue, counter shame, prejudice, and silence; • Build public support for suicide prevention – policies & systems; • Address needs of vulnerable groups – culture & disparities; • Coordinate and integrate health and behavioral health - continuity of care; • Reduce access to lethal means among individuals with identified suicide risks;

and • Apply the most up-to-date knowledge base for suicide prevention.

NSSP & State Plan Strategic Directions1. Create supportive safe environments that promote healthy & empowered individuals, families, and communities 2. Enhance clinical and community preventive services 3. Promote availability of timely treatment & support services4. Improve suicide prevention surveillance collection, research, & evaluation

DMHDDSAS works with other state and local agencies to provide prevention, crisis intervention, treatment, recovery support and other services to people who are most at risk for, contemplating suicide or who have attempted suicide, and to their families.

National Prevention Strategy

Community Wellness, Prevention and Health Integration

• Wellness is:* More than being free from illness or disease.* An active process of change and growth.* Awareness of and making choices toward healthy

and fulfilling life.• Wellness domains interrelate with another:

Emotional Social EnvironmentalPhysical Spiritual Intellectual Occupational

ZeroSuicide

http://zerosuicide.actionallianceforsuicideprevention.org

/

National Action Alliance for Suicide PreventionPartnership of private and public organizations to enhance the goals set forth by

the National Strategy for Suicide Prevention (2012)

One of their focusesGOAL 8: Promote suicide prevention as a core component of health care

services to include promoting “zero suicides”

What is ZERO SUICIDE?Zero Suicide is a commitment to suicide prevention in health and behavioral health care

systems. Its core proposition is that suicide deaths for people under care are preventable and that the bold goal of zero suicides among persons receiving care is an aspirational challenge

that health systems should accept

Zero SuicideStep: Ensuring Every Person Has a Pathway to Care

• Standardized suicide screening of all members enrolled in active behavioral healthcare services.

• Formal assessment by a qualified health or medical provider for anyone screening positive for suicide risk.

• Stratification of the risk, as indicated by the assessment, into low, medium or high risk.

• Engagement of the patient or client in best-practice interventions geared to risk level.

• Follow-up contact from provider or caregiver.

Step: Continuing Contact After Care• After a visit to a behavioral health outpatient setting or primary care, for anyone at risk.

• Between services for those with scheduled care and to engage those not actively engaged in care.

• After discharge from acute care settings

Prevention Partners in NCThe Jason Foundation

QUESTIONS?

NC State UNC Duke

Go Heels!

http://www.trianglesos.com

North Carolina

Key Resources:• American Association of Suicidology• American Foundation for Suicide Prevention• Center for Disease Control: Suicide• Center for Disease Control: Youth Risk Behavioral Surveillance System• Jason Foundation• The Jed Foundation• NAMI (National Alliance on Mental Illness)• National Council for Suicide Prevention• National Strategy for Suicide Prevention (PDF)• Samaritans USA• Suicide Awareness Voices of Education (SAVE)• Tennessee Suicide Prevention Network• Yellow Ribbon Suicide Prevention Program

Resources

For additional information about the National Strategy for Suicide Prevention (NSSP), visit: • http://

www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html

• http://www.samhsa.gov/nssp• http://

www.actionallianceforsuicideprevention.org/NSSP

SAMHSA Resources - Suicide Prevention

Providers:• http://store.samhsa.gov/shin/content//SMA1

3-4793/SMA13-4793.pdfAdministrators:• http://store.samhsa.gov/product/Quick-Guide

-for-Administrators-Based-on-TIP-50/SMA13-4786

High schools: (tool kit)• http://store.samhsa.gov/shin/content//SMA1

2-4669/SMA12-4669.pdf

Thank you for taking the next step…

For more information:NC DMHDDSAS• susan.robinson@dhhs.nc.gov

919-715-2262

NC DPH• jane.miller@dhhs.nc.gov

919-707-5434