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.
Patients at risk for suicide agree to actively engage in a package of evidence-based practices that directly targets their suicidal thoughts and behaviors.
Overview: Suicide Care Management Plan
When an organization makes a commitment to Zero Suicide, every patient who is identified as being at risk for suicide is closely followed through a suicide care management plan or a pathway to care. It is essential to continuously assess risk, engage patients in their collaborative safety plan, treatment plan, and suicide care management plan and re-engage patients at every encounter, no matter what the reason for the visit.
All staff members have crucial roles in preventing suicide. A fundamental premise of the Zero Suicide approach is that safer suicide care begins from the moment a patient calls the organization for an appointment, is assessed, or is admitted for treatment, whichever comes first. Suicide risk immediately becomes a primary focus of assessment in a behavioral health or primary care setting if a patient indicates current or past suicidal thoughts or attempts or is identified as at risk through screening.
Evidence shows that outpatient management of suicidal patients can be safe, clinically appropriate, and, at times, preferable to inpatient care.1 Patients at high risk of suicide are often among the highest percentage of those dropping out of treatment.2 The Joint Commission recommends motivational enhancement strategies to increase the likelihood of engagement in further treatment.3 Improvements in treatment compliance for patients at risk for suicide can be obtained through intensive follow-up, case management, contacts, and visits.1 Research shows that improved ease of access to emergency services can reduce subsequent attempts by those who have made their first suicide attempt.1,3
Several studies have shown that engaging patients by beginning interventions and treatment at or as soon as possible after emergency room or inpatient discharge has demonstrated significant reductions in repeat suicide attempts.4 The risk of a suicide attempt or death is highest within the first month after discharge from inpatient or emergency department care.4 Particularly high-risk periods are the first week and the first day after discharge.4,5 47 percent of those who died by suicide following discharge died before their first follow-up appointment, and 43 percent of suicides occurred within a month of discharge.5 Up to 70 percent of patients who leave the emergency department after a suicide attempt never attend their first appointment.6 The average performance was only 51 percent on the Healthcare Effectiveness Data & Information Set (HEDIS) measure for one completed outpatient visit within seven days of discharge from inpatient psychiatric hospitalization.6,7
Recommendation: Develop a Pathway to Care
Care protocols for patients with high suicide risk are similar to systematic approaches used for other health conditions, such as diabetes or high blood pressure. One protocol for ongoing engagement is a suicide care management plan, also called a pathway to care. Establishing a suicide care management plan involves changes in systems and requires staff buy-in. Implementation policies, outlined in the Zero Suicide Toolkit, include establishing:
- A screening tool, as outlined in the Identify element of Zero Suicide, and criteria to indicate that a patient should be engaged in a suicide care management plan
- Same-day access to behavioral health professionals for those determined to be at immediate risk through use of a standard risk formulation framework
- Requirements and protocols for safety planning, crisis support planning, and lethal means reduction, including the frequency of visits and actions to be taken if a patient misses appointments or drops out of care
- Channels for communicating with a patient about diagnosis, treatment expectations, and what it means to have a suicide care management plan
- A referral process to suicide-specific, evidence-based treatment and requirements for continued contact, especially during transitions in care
- Criteria and protocols for closing out a patient’s suicide care management plan
- Training for all staff at least annually in suicide care management plan policies and protocols and documentation requirements so that they understand the reason for these policies and what is expected of them
- A schedule for regular team meetings and clinical case consultations to discuss patients at risk for suicide
- A schedule for management to regularly review charts to determine that policies and protocols are followed
Conclusion: Engage and Assess at Every Opportunity
Current research suggests that no single approach will reduce suicide among individuals who are in care. Comprehensive, multi-component, system-wide approaches to suicide prevention have been shown to be effective in broad and diverse settings and likely are the keys to reducing suicide.4,5,6,7 The Zero Suicide approach offers a toolkit that guides implementers in the process of embedding interconnecting evidence-based practices for suicide prevention into health care systems.
Engage: Safety Planning
Safety planning is an essential intervention and component of an effective and evidence-based suicide care management plan.
Overview: Collaborative Safety Planning
Recommendation: Engage a Safety Plan
The elements of a safety plan are as follows:9
- Warning Signs - Recognition of the signs that immediately precede a suicidal crisis
- Internal Coping Strategies - Things patients can do to distract themselves without contacting anyone
- Social Situations That Can Help Distract Me - Places patients can easily access that provide a safe environment (a library, mall, coffee shop, etc.)
- People I Can Ask for Help - At least three support persons; persons who are available, able to provide support, aware of resources, and informed that they are a part of the safety plan
- Professionals or Agencies I Can Contact During a Crisis - Professionals and crisis support agencies including the hours and contact information for current treatment provider, local and regional crisis support, and national crisis support providing 24/7 crisis services
- Making the Environment Safe - Steps to remove access to lethal means, strategies to limit or eliminate substance use, and any other strategies to maintain a safe environment
Research shows that individuals with higher-quality safety plans are less likely to be hospitalized in the year after safety planning.8,14 Interviews with 100 veterans in a qualitative study found that 97 percent were satisfied with their safety plan, 61 percent reported using their plan, and 20 percent reported making changes to their safety plan on their own or with a professional. For those using the safety plan, the aspects that veterans reported were most helpful included social contacts, places for distraction, social support for crisis help, contacting professionals, and internal coping strategies.14,15 A recent study found that crisis planning reduced suicide attempts, reduced inpatient hospitalization, and was associated with a faster decline in suicidal ideation in high-risk active duty soldiers.11
Conclusion: Collaborate for Accountable Care
Engage: Reducing Access to Lethal Means
Reducing access to lethal means is an essential step in safety planning.
Overview: Reducing Access to Lethal Means Works
A key component of Zero Suicide and other effective suicide prevention strategies is reducing access to methods that could be used for suicidal acts and, if possible, restricting access during an acute suicidal crisis. Reducing access to lethal means—particularly those with greater lethality—is essential in safety planning.
Studies around the world have demonstrated that the overall rate of suicide drops when access to commonly-used, highly lethal suicide methods is reduced.17,18,19 In the late 1950s, the United Kingdom switched from coal gas to natural gas, which is free from carbon monoxide.17 Suicide deaths decreased, saving thousands of lives over the next 10 years. A study in Australia found a decrease in suicide by firearms and in the overall national suicide rate following a 1998 ban on private gun ownership.19
Every safety plan should address reducing access to any lethal means that are available to the patient. Limiting access to medications and chemicals and removing or securing firearms, other weapons, and ligatures are important actions to keep patients safe. This is particularly important in light of findings about the impulsivity of many suicide attempts. Among people who made near-lethal suicide attempts, 24 percent reported taking less than five minutes between the decision to kill themselves and the actual attempt. 70 percent took less than an hour.20
Based on this evidence, it is clearly possible to increase the chance of surviving an attempt if an individual at risk for suicide has reduced access to lethal means in their moment of crisis. This also has longer-term implications for these individuals. 90 percent of individuals who attempt suicide will not go on to die by suicide at a later time.21 Even with underlying or chronic risk factors, a person’s suicidal crisis is often of short duration and a treating team can significantly help an at-risk individual by limiting access to lethal means.17,22 Additional evidence supports that availability of method influences choice of method. If a favored method becomes less available, individuals do not necessarily engage in means substitution.22
Recommendation: Establish Specific Protocols and Effective Policies
Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with an individual at risk for suicide. The Counseling on Access to Lethal Means (CALM) online training is offered free of charge by the Suicide Prevention Resource Center.23 The training is designed to increase knowledge of the association between access to lethal means and suicide and the role of means restriction in prevention. The course is also intended to increase a provider’s skills and confidence to assess and reduce a patient’s access to lethal means.
Research shows that mental health providers demonstrated an increase in knowledge and skills regarding lethal means reduction counseling and sustained change in beliefs and attitudes about the importance of lethal means restriction following a CALM training.23 At 6-week follow-up from a CALM training, 65 percent of providers reported already counseling on means reduction.24
As a part of the Zero Suicide approach, it is recommended that this training—paired with site-specific policies about reducing access to lethal means—be required of all clinical and, in some cases, non-clinical staff members.
Specific attention should be paid to protocols about reducing access to firearms. Firearms are the most common method of suicide in the U.S., and more people die by suicide via this method than all other methods combined.17 Every U.S. study that investigated the relationship between firearms and suicide has found that access to firearms is a risk factor for suicide.17
Organizational policies should clearly state what clinicians are expected to do regarding lethal means. Policies should include the protocol to follow in the event that a patient brings a weapon or other lethal means into a clinical setting. Policies and training should reflect specific steps that clinical and non-clinical staff can take to reduce access to lethal means. These include the process for securing weapons and medications and the conditions under which they may be returned.
Conclusion: Reducing Access to Lethal Means is an Essential Step
It is essential to assist patients through a crisis by actively engaging them to reduce their access to lethal means. Engagement also means developing an individualized collaborative safety plan, encouraging active participation in treatment, and providing patients with a clear roadmap to their care. Using these approaches, clients are more likely to get through their short-term suicidal crisis safely and experience long-term recovery.
- 1. a. b. c. Oordt, M. S., Jobes, D. A., Rudd, M. D., Fonseca, V. P., Runyan, C. N., Stea, J. B., Campise, R.L., & Talcott, G. W. (2005). Development of a Clinical Guide to Enhance Care for Suicidal Patients. Professional Psychology: Research & Practice, 36(2), 208-218. Retrieved from https://utah.pure.elsevier.com/en/publications/development-of-a-clinical...
- 2. Rudd, M.D., Rajab, M.H., Orman, D.T., Stulman, D.A., Joiner, T., & Dixon, W. (1996). Effectiveness of an outpatient intervention tar geting suicidal young adults: Preliminary results. Journal of Consulting and Clinical Psychology, 64(1), 179-190. Retrieved from https://utah.pure.elsevier.com/en/publications/effectiveness-of-an-outpa...
- 3. a. b. The Joint Commission. (2016). Sentinel Event Alert, Issue 56: Detecting and treating suicide ideation in all settings. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf
- 4. a. b. c. d. Knesper, D. J., American Association of Suicidology, & Suicide Prevention Resource Center. (2011). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Retrieved from http://www.sprc.org/sites/default/files/migrate/library/continuityofcare...
- 5. a. b. c. Hunt, I. M., Kapur, N., Webb, R., Robinson, J., Burns, J., Shaw, J., & Appleby, L. (2009). Suicide in recently discharged psychiatric patients: a case-control study. Psychological Medicine, 39(3), 443-449. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18507877
- 6. a. b. c. Luxton, D., June, J., & Comtois, K. (2013). Can postdischarge follow-up contacts prevent suicide and suicidal behavior? Crisis, 34(1), 32-41. Retrieved from http://econtent.hogrefe.com/doi/abs/10.1027/0227-5910/a000158
- 7. a. b. Group Health Cooperative. (2016). 2015 HEDIS and CAHPS Measures and Performance. Retrieved from https://www1.ghc.org/static/pdf/public/about/hedis.pdf
- 8. a. b. c. d. e.
- 9. a. b. c. Stanley, B. & Brown, G. K. (2008). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. Retrieved from http://www.mentalhealth.va.gov/docs/va_safety_planning_manual.pdf
- 10. Rudd, M., Mandrusiak, M., & Joiner, T. (2006). The Case Against No-Suicide Contracts: The Commitment to Treatment Statement as a Practice Alternative. Journal of Clinical Psychology, 62(2), 243-251. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/jclp.20227/full
- 11. a. b. Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., & Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 264-272. Retrieved from http://www.jad-journal.com/article/S0165-0327(16)31947-4/ppt
- 12. a. b. c. Stanley, B. & Brown, G. K. (2016). Safety Planning Intervention: A brief intervention for reducing suicide risk. Retrieved from http://www.suicidesafetyplan.com/About_Safety_Planning.html
- 13. a. b. Stanley, B. (2013, July). The Safety Planning Intervention and Other Brief Interventions to Mitigate Risk with Suicidal Individuals. Presented at the Texas Suicide Prevention Symposium, Irving, TX. Retrieved from: http://www.texassuicideprevention.org/wp-content/uploads/2013/06/TexasSu...
- 14. a. b. Stanley, B., Chaudhury, S. R., Chesin, M., Pontoski, K., Bush, A. M., Knox, K. L., & Brown, G. K. (2016). An emergency department intervention and follow-up to reduce suicide risk in the VA: acceptability and effectiveness. Psychiatric Services, 67(6), 680-683. Retrieved from http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201500082
- 15. a. b. Brenner, L., Brown, G. K., & Stanley, B. (2015, December). Safety Planning Intervention: Current Evidence Base and Innovations. Presented at the U.S. Department of Veterans Affairs’ Health Services Research & Development Cyber Seminar, virtual meeting. Retrieved from http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/...
- 16. Chesin, M. S., Stanley, B., Haigh, E. A., Chaudhury, S. R., Pontoski, K., Knox, K. L., & Brown, G. K. (2017). Staff views of an emergency department intervention using safety planning and structured follow-up with suicidal veterans. Archives of Suicide Research, 21(1), 127-137. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27096810
- 17. a. b. c. d. e. Harvard T.H. Chan School of Public Health. (2016). Means Matter. Retrieved from https://www.hsph.harvard.edu/means-matter/
- 18. Hawton, K. (2002). United Kingdom legislation on pack sizes of analgesics: Background, rationale, and effects on suicide and deliberate selfharm. Suicide and Life-Threatening Behavior, 32(3), 223-229. Retrieved from http://onlinelibrary.wiley.com/doi/10.1521/suli.126.96.36.19969/full
- 19. a. b. Large, M.M., & Nielssen, O.B. (2010). Suicide in Australia: Meta-Analysis of Rates and Methods of Suicide between 1988 and 2007. Medical Journal of Australia, 192(8), 432-437.
- 20. Mercy, J.A., Kresnow, M.J., O’Carroll, P.W., Lee, R.K., Powell, K.E., Potter, L.B., & Bayer, T.L. (2001). Is suicide contagious? A study of the relation between exposure to the suicidal behavior of others and nearly lethal suicide attempts. American Journal of Epidemiology, 154(2), 120-127. Retrieved from https://academic.oup.com/aje/article/154/2/120/80422/Is-Suicide-Contagio...
- 21. Owens, D., Horrocks, J., & House, A. (2002). Fatal and non-fatal repetition of self-harm: Systematic review. British Journal of Psychiatry, 181, 193-199. Retrieved from https://msrc.fsu.edu/system/files/Owens%20et%20al%202002%20Fatal%20and%2... self-harm.pdf
- 22. a. b. Hawton, K. (2007). Restricting access to methods of suicide: Rationale and evaluation of this approach to suicide prevention. Crisis, 28(1), 4-9. Retrieved from http://econtent.hogrefe.com/doi/abs/10.1027/0227-5910.28.S1.4
- 23. a. b. Suicide Prevention Resource Center. Counseling on Access to Lethal Means (CALM). Retrieved from https://go.edc.org/CALMonline
- 24. Johnson, R.M., Frank, E.M., Ciocca, M., & Barber, C.W. (2011). Training mental health care providers to reduce at-risk patients’ access to lethal means of suicide: Evaluation of CALM Project. Archives of Suicide Research, 15(3), 259-264. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21827315