Broad Implementation Overview
Avera serves South Dakota and the surrounding areas of Minnesota, Iowa, Nebraska, and North Dakota through six regional centers in Aberdeen, Mitchell, Pierre, Sioux Falls, and Yankton, South Dakota, and Marshall, Minnesota. The Avera Health System includes 33 hospitals, 208 primary and specialty care clinics, and 40 senior living facilities, in addition to home care and hospice, sports and wellness facilities, home medical equipment outlets and more. In 2015, Avera senior leadership (i.e., the medical director and administrators) attended a Zero Suicide Academy in Baltimore, Maryland. In the fall of that year, Avera held a Zero Suicide kickoff. During the event, the parent of a person who had died by suicide shared her personal story, and key Avera leadership shared local suicide data and plans for implementing Zero Suicide across the Avera Health System. The event was recorded and distributed via our learning management system to communicate the launch of Zero Suicide and to share concrete action steps with all staff. The kickoff also helped develop a shared vision and create buy-in among clinical staff.
A Zero Suicide initiative steering committee was also formed in the fall of 2015. The committee helped facilitate both the introduction of an assessment of workforce readiness for providing care to patients at risk of suicide across all behavioral health locations (Avera adapted the Zero Suicide Workforce Survey) and the subsequent delivery of trainings and education in suicide-specific interventions. The survey identified ways that staff engaged with clients with suicidal thoughts and behaviors and areas in which they would like more training, resources, and support. Suicide prevention-specific trainings and educational opportunities were identified for all clinical and nonclinical staff based on the survey findings. These training opportunities were designed to address gaps in workforce readiness as identified by the survey and to ensure clinicians implemented new clinical practices with fidelity.
Impact of Training and Suicide Care Interventions
With leadership from our steering committee and guidance from the Zero Suicide Workforce Survey findings, Avera implemented new suicide-specific interventions and enhanced the standard suicide-specific interventions already in use across the health system. These interventions included screening with the Patient Health Questionnaire-9 (PHQ-9,) suicide risk assessment using the Columbia Suicide Severity Rating Scale (C-SSRS), collaborative safety planning, and lethal means counseling. Educating staff in these standard interventions and clinical workflow was led by Avera behavioral health clinical educators. In addition, a local community partner, the Helpline Center, helped provide some trainings, including in-service trainings for behavioral health staff in Question, Persuade, Refer (QPR for nonclinical staff) and Question, Persuade, Refer, Treat (QPRT for clinical staff).
Avera Health uses its system-wide Meditech Electronic Health Record (EHR) to track clinician compliance in delivering the above interventions implemented with Zero Suicide. The use of the EHR helps track clinician adherence to protocols and procedures and identifies completion of interventions intended to implement and to support the care of the patient.
Data for the latest fiscal year (July 2017 to June 2018) showed the following among all patients who received inpatient services at any of our three behavioral health locations:
- 91.9% received a PHQ-9 screening.
- 87.5% received the C-SSRS screening if they stated suicidal ideation in question 9 of the depression screening.
- 92.4% had developed a safety plan.
- 95.5% received lethal means counseling.
Over the same time period, we observed a 52% reduction in emergency psychiatric assessments (i.e., psychiatric assessments that occur in an emergency care setting or a behavioral health location). Avera tracks emergency psychiatric assessments among patients with suicidal ideation based on question 9 of the PHQ-9 and patients who had an inpatient stay and then returned for a psychiatric assessment in an emergency care setting in our system after discharge. We hypothesize that this reduction is related to an increase in patients receiving interventions that were enhanced or implemented as part of Avera’s Zero Suicide initiative, such as a written safety plan, timely outpatient follow-up care (e.g., follow-up appointment, medication management, or other visit within seven days), and community supports.
“Continuous collaboration between behavioral health staff and quality and data analysts ensures transparency and enables our data to assist with improvement in documentation and patient care. This effort to partner and integrate various experts within the organization is part of our culture to evaluate progress and intentionally improve quality.”
Readmission Outcomes Related to Suicide Care Interventions
From July 2016 to June 2018, among patients who were discharged from inpatient behavioral health, Avera observed the following:
- Emergency department admissions decreased by 32%.
- Admissions to either the emergency department or an inpatient setting of patients with suicidal ideation on question 9 of the PHQ-9 decreased by 45%.
Provider and medical coder education were provided to improve the accuracy of self-harm coding related to these outcomes. These outcomes may be tied to increased implementation of collaborative safety plans, standardizing counseling on access to lethal means, and providing timely outpatient follow-up care as outlined above.
Culture Change and Awareness across the Avera Health System
Screening for depression and suicide risk is expanding at Avera beyond behavioral health inpatient and outpatient services. Increased awareness of suicide prevention across Avera has brought suicide and behavioral health care to the forefront of treatment in all settings. For example, Avera emergency departments, primary care clinics, critical access hospitals, and acute inpatient medical departments have already implemented or will begin screening for depression and suicide risk. In addition to enhance care transitions, Avera is enhancing opportunities for patients to have rapid access to counseling and psychiatric consultation. Culture is important to our organization, and as a central part of the Avera mission to care for the whole person—body, mind, and spirit—Avera will continue to advance compassionate, supportive care to prevent suicide and improve the lives of patients and families in our communities and region.
Continuous collaboration between behavioral health staff and quality and data analysts ensures transparency and enables our data to assist with improvement in documentation and patient care. This effort to partner and integrate various experts within the organization is part of our culture to evaluate progress and intentionally improve quality.
Avera’s Zero Suicide initiative will continue to grow over time and will expand from the behavioral health setting to other settings (i.e., non-behavioral health medical units, primary care clinics, and critical access hospitals). It is a priority for the health system to expand depression screening and suicide risk assessment. We are also in the process of implementing Brief-Cognitive Behavioral Therapy (B-CBT) as a model to improve the way crisis response planning, means safety counseling, and skills groups are provided.
Avera continues to learn from the available data and to develop ways to capture additional data to evaluate the Zero Suicide initiative’s impact on reducing suicide attempts and rates of death by suicide. Avera’s relationship with the State of South Dakota over the course of several years has assisted in this effort, and we plan to enhance our collaboration to increase access to data related to suicide deaths and suicide attempts. It is our hope that these efforts will yield improvements in data collection and the evaluation of the impact of the Zero Suicide initiative.