A Suicide Prevention Toolkit for Rural Primary Care

1
A Suicide Prevention Toolkit for Rural Primary
Care

• IHS National Behavioral Health Conference,
• August 7, 2009
• Peggy West PhD MSW
• Senior Advisor
• Suicide Prevention Resource Center
• pwest_at_edc.org

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Overview

• Toolkit Development
• Why Rural?
• Why Primary Care?
• Primary Care Suicide Prevention Model
• Overview of Toolkit Components
• Next Steps

3
Toolkit Development

• WICHE/Mental Health Program HRSA
• AHECArea Health Education Center at U. CO
• SPRCSAMHSA
• Formative evaluation
• Reviewers (AHEC provider and community
  committees)
• Pilot webinar U CO interdisciplinary health
  professions students in rural track
• American Association of Suicidology
  Conferencepanel presentation

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Suicide Rates in Rural vs. Non-Rural

• Rural men have twice the suicide rate of their
  urban counterparts.
• Suicide rates for young women were 85 higher in
  rural
• Suicide rates for working-age women were 22
  higher in rural.
• Widening rural-urban differentials in male
  suicides over time.
• Singh GK, Siahpush M. The increasing rural urban
  gradient in US suicide mortality, 1970,-1997 Am J
  Public Health. 2003 July 200393(5)1161-1167

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Suicide Mortality Rural vs. Urban by Gender
Singh GK, Siahpush M. The increasing rural urban
gradient in US suicide mortality, 1970,-1997 Am J
Public Health. 2003 July 200393(5)1161-1167
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Violent Deaths in Rural vs. Non-Rural

• Suicide rates were 31 - 43 higher in
  nonmetropolitan counties
• Suicide rates were 80 higher in rural Western
  U.S. among male residents

Peek-Asa, Corinne PhD, MPH Zwerling, Craig PhD,
MD, MPH Stallones, Lorann PhD, MPH Acute
Traumatic Injuries in Rural Populations AJPH
Volume 94(10)   October 2004   1689-1693
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Non-firearm Suicide and HomicideRural vs.
Non-Rural

• Branas CC, Nance ML, Elliott MR, Richmond TS,
  Schwab CW. (2004).Urban-Rural Shifts in
  Intentional Firearm Death Different Causes, Same
  Results. AJPH, 9410, 1750-1755

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Firearm Suicide and HomicideRural vs. Non-Rural
Branas CC, Nance ML, Elliott MR, Richmond TS,
Schwab CW. (2004).Urban-Rural Shifts in
Intentional Firearm Death Different Causes, Same
Results. AJPH, 9410, 1750-1755
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Suicide, by county
http//www.cdc.gov/ncipc/maps/default.htm

• Red 75th national percentile
• Blue 50th national percentile
• Gray 25th national percentile
• White lt25th national percentile

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Rural Structural Factors

• Inadequate medical/mental health resources
• Funding inequities and need for sustainability
• Workforce capacity and health integration issues
• Limitations and lack of integration of services
  and providers
• Recruitment and retention of staff
• 75 of rural counties have no psychiatrist, 95
  no child psychiatrist
• Small counties (lt2500) 33 have no mental health
  professionals
• Changing cultural population needs (lack of
  capacity for culturally competent and language
  appropriate services)

Source Advancing Suicide Prevention,
Fall/Winter 2004-5.
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Why Primary Care?

• Preventive care focus
• Contact with individuals at risk for suicide not
  in other systems of care/contact
• PCs frequent source of psychotropic medications

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Contact with Primary Care and Mental Health Prior
to Suicide

• Luoma J, Martin C, Pearson J. Contact with Mental
  Health and Primary Care Providers Before Suicide
  A Review of the Evidence Am J.Psychiatry 1596
  (2002) 909-916.

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Salient Risk Factors Observed in Primary Care
Settings

• Major depression
• Substance use disorders
• PTSD/anxiety disorders
• Insomnia
• Chronic pain
• Physical illnesses, especially CNS disorders
  (TBI)

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Patient Education Roles for PC

• Suicide warning signs response
• Safe firearm storage

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Safe Firearm/Ammunition Storage
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Primary Care Suicide Prevention Model

• Prevention Practices
• Staff vigilance for warning signs key risk
  factors
• Universal depression screening for adults and
  adolescents
• Patient educationSafe firearm storageSuicide
  warning signs 1-800-273-TALK (8255)

Intervention
No screeningnecessary
Warning signs, major depression, anxiety,
substance use disorder, insomnia, chronic pain,
PTSD, TBI
No
Yes
No
Rescreenperiodically
Screen for presence of suicidal thoughts
Yes
Suicide Risk Assessment
Risk Management referral, treatment initiation,
safety planning, crisis support planning,
documentation, tracking and follow up
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Toolkit Overall Layout

• The Toolkit is available in 2 forms
• Hard copy, spiral bound ordered through WICHE
• Electronic copy (www.sprc.org)
• Includes 6 sections
• Getting started
• Educating clinicians and office staff
• Developing mental health partnerships
• Patient management tools
• Patient education tools
• Resources

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1. Getting Started
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1. Getting Started
To be used with instruction sheet to create an
office protocol that may be referred to when a
potentially suicidal patient presents
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2. Educating Clinicians and Office Staff

• Primer with 5 brief learning modules
• Module 1- Prevalence Comorbidity
• Module 2- Epidemiology
• Module 3- Effective Prevention Strategies
• Module 4- Suicide Risk Assessment
• Warning Signs, Risk Factors, Suicide Inquiry,
  Protective Factors
• Module 5- Intervention
• Referral, PCP Intervention, Documentation
  Follow-up

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Primer
Aggressive treatment of psychiatric and substance
use disorders is an important part of a
comprehensive, primary-care based approach to
suicide prevention.
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3. Developing Mental Health Partners

• Letter of introduction to potential referral
  resources--template
• Increasing vigilance for patients at risk for
  suicide
• Referring more patients
• SAFE-T card for Mental Health Providers
• Invitation to meet to discuss collaborative
  management of patients
• NSSP recommends training for health care
  professionals
• Nationally disseminated trainings for MHPs

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3. MH Partners
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3. MH Partners Telemental Health

• Web-based guide for development telemental health
  capacity (created by the U CO Denver as part of
  SAMHSAs Eliminating Health Disparities
  Initiative) www.tmhguide.org
• Resources for
• Clinicians/Administrators
• Consumers
• Policymakers
• Community Members
• Media 

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3. MH Partners

• SAMHSA mental health and substance abuse
  treatment locator guides (www.samhsa.gov)
• Veterans resource locator (http//www.suicidepreve
  ntionlifeline.org/Veterans/ResourceLocator.aspx)

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4. Patient ManagementPocket Card
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4. Patient ManagementPocket Card
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4. Patient ManagementPocket Card
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4. Patient Management

• Safety Plan
• Collaboratively developed with patient
• Template that is filled out and posted
• Includes lists of warning sings, coping
  strategies, distracting people/places, support
  network with phone numbers
• Crisis Support Plan
• Provider collaborates with Pt and support person
• Contract to help- includes reminders for ensuring
  a safe environment contacting professionals
  when needed

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4. Patient Management
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4. Patient Management
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4. Patient Management - Tracking Log

• Log Instruction sheet
• Provider uses
• Update PCP on suicide status of a patient
• Remind provider of recent interventions or
  problems with regard to the patients treatment

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Tracking Log
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5. Patient Education
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6. Resources

• Resource list for providers
• Associations Organizations
• Other resources with links for downloading or
  ordering
• Posters and brochures for clinics

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Next Steps

• Formal pilot testing
• Dissemination
• Conferences
• Rural health
• Primary care guilds

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Next Steps

• Further development ideas
• Tailoring for specific patient groups (e.g.,
  pediatrics, veterans, military, elders)
• Additional tools
• Financing
• Preventing suicides among PC providers and staff
• Postvention
• Translation into training curricula for
  clinicians and staff

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Questions?
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Recommendations for reducing financial barriers

• Medicaid Medicare reimbursement
• Federally Qualified Health Centers (FQHC) can use
  cost based reimbursement and
• Medicaid Early Periodic Screening Diagnosis and
  Treatment (EPSDT) policy requires Medicaid to
  cover treatment of conditions detected in
  screening services.
• Medicare negotiate patient payment arrangements
  prior to delivery of non Medicare covered Mental
  Health services
• Establish referral and consultation linkages with
  public mental health services
• Reimbursement of Mental Health Services in
  Primary Care Settings, February, 2008 by SAMHSA,
  U.S. DHHS. (white paper) includes recommendations
  for addressing barriers in Medicaid and Medicare

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Recommendations for reducing financial barriers

• Private Insurance
• 1. Implement parity in benefit packages
• 2. Allow primary care clinicians reimbursement on
  mental health diagnostic codes
• 3. Reimburse treatments which go beyond patient
  contact, i.e. parent contact, family meetings,
  collateral consults
• 4. Co-location of mental health professionals in
  medical settings
• 5. Development and use of inter-professional
  electronic communications including telemedicine
• American Academy of Child and Adolescent
  Psychiatry Committee on Health Care Access and
  Economics, Pediatrics, Vol 123, Number 4, April
  2009

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• Barriers for Primary Care Providers in
  Recognizing and Addressing Suicide Risk in
  Patients

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Personal Barriers

• Myths and stigma regarding suicide
• Personal experiences with suicide
• family
• friends
• patients

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Professional Barriers

• Lack of
• Experience with suicide risk factors and warning
  signs
• Expertise/confidence in asking questions about
  suicidal thoughts
• Understanding about how to involve family and
  support networks
• Experience in responding to patient disclosures
  about suicidal ideation/plans

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Professional Barriers cont.

• Lack of
• Knowledge about safety planning
• Awareness of community resources
• Training for office support staff for back up
  assistance
• Fear of liability and legal complications

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Organizational, Administrative Barriers

• Every seven minutes
• No office procedures to follow or triage
• Financing policies for mental health service
• No mental health resources in the community

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Toolkit Development

• WICHE/Mental Health Program HRSA
• AHECArea Health Education Center at U. CO
• SPRCSAMHSA
• Formative evaluation
• Reviewers (AHEC provider and community
  committees)
• Pilot webinar U CO interdisciplinary health
  professions students in rural track
• American Association of Suicidology
  Conferencepanel presentation

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Reviewer Feedback

• Reviewed by 17 providers 10 community members
• Reviewers were provided hardcopy electronic
  versions
• Utilized an online survey tool
• Providers were asked questions about their
  perceptions on suicide as a problem the
  potential utility of the toolkit in their
  practice
• Consumers were invited to provide general feedback

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Feedback Provider perceptions about suicide

• Suicide is a serious problem in my community.
• Disagree 5.9
• Neutral 23.5
• Agree 58.8
• Strongly Agree 11.8
• Better suicide prevention efforts are needed in
  my community.
• Neutral 33.3
• Agree 46.7
• Strongly Agree 20

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Feedback Provider Perceptions about the Toolkit

• Providers overwhelmingly agreed that
• Reviewing the Toolkit added to their suicide
  prevention knowledge base
• Reviewing the Toolkit increased their confidence
  in working with suicidal patients
• Using the information and tools contained in the
  toolkit has the potential to improve outcomes
  with suicidal patients
• The toolkit as a whole is a useful product

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Feedback Provider perceptions of the Toolkit

• Providers were asked which components of the
  Toolkit they would use in their practice if they
  had the opportunity
• Risk assessment Pocket Cards 87.5
• Crisis Response Planning Tools 87.5
• Primer 68.8
• Office Protocol 68.8
• Treatment Tracking Log 56.3
• Community Education Materials Resource List and
  posters 56.3
• The primary reason cited for not using a Toolkit
  component was already having a similar tool in use

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Feedback Provider Perceptions of the Toolkit

• Providers were asked which components they would
  share with a colleague given the opportunity
• Risk assessment Pocket Cards 93.8
• Crisis Response Planning Tools 87.5
• Primer 75
• Office Protocol 75
• Community Education Materials Resource List and
  posters 68.8
• Treatment Tracking Log 56.3

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Feedback Community Members

• Community Advisory Board- experienced in
  reviewing medical/professional materials
• Overwhelmingly agreed that
• The toolkit as a whole is organized and clear
• The Toolkit added to their suicide prevention
  knowledge base
• Use of the Toolkit has the potential to improve
  outcomes with suicidal patients in my community
• The Toolkit as a whole is a useful product

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Feedback Community Members

• General feedback
• Respondents liked that the fact that the toolkit
  focused on education
• Endorsed education of providers and community
  members as the most important aspect of suicide
  prevention in their communities and wanted
  increased efforts in these areas
• Wanted more educational materials for patients,
  as well as family and friends of people at risk
  for suicide