When an organization makes a commitment to Zero Suicide, every patient who is identified as being at risk for suicide is closely followed. He or she is engaged and re-engaged at every encounter no matter the reason for the visit.
We call this plan for continuous engagement a Suicide Care Management Plan or a pathway to care.
Organizations that have reported the most success providing patients with a pathway to care use the electronic health record (EHR) to flag patients at risk of suicide.
In a Zero Suicide approach:
- All individuals identified to be at risk of suicide are engaged in a Suicide Care Management Plan.
- The patient’s status on a suicide care management plan is monitored and documented in an electronic health record (EHR).
What is our approach to caring for and tracking individuals at risk for suicide?
To Implement Zero Suicide
Design Suicide Care Management Policies
Design policies and procedures for engaging a patient in a Suicide Care Management Plan, which should specify the following:
- The screening tool and criteria to indicate that the patient should be engaged in a suicide care management plan
- Provision of same-day access to a behavioral health professional for formulation of a clinical judgment of risk using a standard risk formulation framework
- Requirements and protocols for safety planning, crisis support planning, and lethal means reduction
- The frequency of visits for a patient with a suicide care management plan and actions to be taken when the patient misses appointments or drops out of care
- The process for communicating with a patient about diagnosis, treatment expectations, and what it means to have a suicide care management plan
- Requirements for continued contact with and support for the patient, especially during transitions in care
- The referral process to suicide-specific, evidence-based treatment
- How documentation of progress and symptom reduction will take place
- Criteria and protocols for closing out a patient’s Suicide Care Management Plan
For more information about designing safety planning, crisis support, and lethal means reduction interventions, click on the Patient Engagement tab above.
Implement Suicide Care Management Policies
Change systems and get staff buy-in so that policies will be followed by:
- Establishing use of the EHR to monitor patients in a Suicide Care Management Plan.
- Training all staff in use of the Suicide Care Management Plan features of the EHR.
- In the absence of an EHR, ensuring all staff clearly document patient status in a Suicide Care Management Plan in the paper record.
- Training all staff at least annually in Suicide Care Management Plan policies and protocols so they know what is expected of them and the philosophy behind these policies.
- Establishing a schedule for regular team meetings and clinical case consultations to discuss patients at risk.
- Setting a schedule for management to regularly review charts to determine that policies and protocols are being followed.
Experience has shown that using an EHR is a key factor in consistently engaging patients in a Suicide Care Management Plan. To learn more about how to use the EHR to monitor patients at risk for suicide, click on the Electronic Health Record tab above.
Active Engagement for Safer Suicide Care
Engaging the Patient
A fundamental premise of the Zero Suicide approach is that safer suicide care begins from the moment the patient calls the organization for an appointment or is admitted for treatment. For example, suicide risk immediately becomes a primary focus of assessment in a behavioral health or primary care setting if a patient indicates that he or she is currently having suicidal thoughts, has had suicidal thoughts in the past, or has made prior attempts.
Another fundamental premise is that all staff members have a crucial role in preventing suicide. At every encounter with a patient who is at risk of suicide, suicide risk should be assessed. This attention to suicidal patients by all staff members, clinical and non-clinical, requires a fundamental shift in what a health or behavioral health organization sees as its role.
Although a great deal of the focus of Zero Suicide is keeping patients safe from harm, engaging patients is not solely about making sure that they come in for sessions. The goal is for patients to grow, gain skills, and recover.
Actively engaging a patient about suicide risk includes the following:
- Takes into account the individual’s experiences and resources
- Builds hope for recovery
- Empowers the individual to resolve crises and long-term problems using the least invasive methods possible
The result of active engagement in suicide care is that the patient feels heard, cared for, and empowered to make safe decisions.
Care that focuses on suicidal thoughts and behavior may be new and even overwhelming to apatient and family. The collaborative, nonjudgmental, comprehensive approach that is part of Zero Suicide may be a very different experience for many patients with suicide risk, especially if prior treatment has failed them. Staff members will need to take care to let patients know what to expect and guide them in how to use treatment effectively.
The following sections cover the fundamentals of engaging patients in safer suicide care.
All individuals identified as at risk of suicide in primary care practices and clinics, hospitals and emergency departments, behavioral health organizations, and crisis services should have a safety plan.1
Collaborative safety planning is becoming standard practice in many behavioral health organizations and health systems. A safety plan is a prioritized written list of coping strategies and sources of support developed by a clinician in collaboration with patients who are at high risk for suicide.
A safety plan should:
- Be brief, in the patient’s own words, and easy to read
- Involve family members as full partners in the collaborative process, especially to establish their role in responding to patient crises
- Include a plan to restrict access to lethal means, which is also balanced with respect to legal and ethical requirements under federal and state laws
- Be updated whenever warranted
- Be in the patient’s possession when she or he is released from care2
Safety Planning Intervention for Suicide Prevention is an online resource that we recommend be reviewed by all staff, clinical as well as relevant nonclinical staff. You’ll find a link to the resource on this page to the right.
Reducing Access to Lethal Means
Every safety plan should address reduction to access to any lethal means that are available to the patient. Limiting access to medications and chemicals and removing or locking up firearms and other weapons are important actions to keep patients safe.
Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with a patient. The Counseling on Access to Means (CALM) online training is offered free of charge by the Suicide Prevention Resource Center. We recommend that it be required of all clinical—and in some cases non-clinical—staff members. A link to the training is provided in the Tools section.
Organization policies should clearly state what clinicians should do regarding lethal means, including the protocol to follow in the event a patient brings a weapon or other lethal means to the clinical setting. As an example, Centerstone’s Securing Weapons for Suicidal/Homicidal Clients can be found in Tools. This protocol outlines the steps for clinical and non-clinical staff to take when a patient brings a lethal instrument to a session. Centerstone is a large not-for-profit provider of community-based behavioral healthcare.
- 1. Western Interstate Commission for Higher Education. (2015). Safety planning guide. Waltham, MA: Education Development Center. Retrieved from http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Gu...
- 2. Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. Retrieved from http://www.suicidesafetyplan.com/uploads/Safety_Planning_-_Cog___Beh_Pra...
Using the Electronic Health Record
Rationale for EHRs
Health and behavioral health organizations should take steps to ensure that a patient’s suicide risk is reviewed at each visit and that care is coordinated among professionals within and outside of the organization.
Building the capacity for tracking patients in an electronic health record (EHR) system can help to ensure that patients at risk are continuously and deliberately monitored. However, not all organizations have a comprehensive EHR system. Nevertheless, every organization should attempt to record suicide screening results, risk formulation, and suicide-specific care plans in each patient’s record. Paper records should be reviewed periodically to ensure that suicide risk is being assessed and recorded by each staff member designated to do so.
Example from the Field
The Institute for Family Health (IFH) is one organization at the forefront of using the EHR in service of a Zero Suicide initiative and providing safer suicide care.
Perhaps the most important advice from IFH’s experience is to include someone from the organization’s information technology (IT) department on the Zero Suicide implementation team from the very beginning.
For details on how IFH uses the EHR in suicide safer care, watch the video Modifying an EHR in which Virna Little, senior vice president for psychosocial services at IFH, describes how IFH modified their EHR to support better suicide care management.
Engage Patients in a Suicide Care Management Plan
The basic next steps to engage patients at risk are to:
- Design policies and procedures for engaging a patient in a suicide care management plan
- Change systems and create staff buy-in so that policies will be followed
- Establish use of the EHR or paper record to monitor clients in a suicide care management plan.
At the same time, examine the use of electronic and/or paper health records to support these processes.
There are several additional items to help you plan these next actions:
Quick Guide to Getting Started with Zero Suicide. This one-page tool lists ten basic actions to take to implement a Zero Suicide initiative. Use this tool to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.
Zero Suicide Organizational Self-Study. Every organization should complete the self-study as one of the first steps in adopting a Zero Suicide approach. While the self-study is available on the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.
Zero Suicide Work Plan Template. This form contains an expanded list of action steps to guide your implementation team in creating a full work plan to improve care and service delivery in each of the seven core Zero Suicide components.