Hello, everyone, and welcome. I am Jose Villareal, founder of Thrive for Wellness and community care expert for SMI Advisor. I am pleased that you are joining us for today's webinar. The topic is Zero Suicide, Taking a Systems Approach to Suicide Prevention in Healthcare. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinical community, our interdisciplinary team has been designated to help you get the answers you need for the care of your patients. Next slide. Today's webinar has been designated for one AMA, PRA category one credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credits for participating in today's webinar will be available until April 15th of 2024. Slides from the presentation today are available to download in the webinar chat. Just select the link to view. Captioning for today's presentation is also available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcripts to open the caption in the side window. Please feel free to submit your questions throughout the presentation by typing them in the questionnaire. Found in the lower portion of your control panel, we'll reserve 10 to 15 minutes at the end of the presentation for some Q&A. And now I would like to introduce today's faculty that's going to be leading the webinar, Dr. Teresa Humphreys-Wetworth. Dr. Teresa Humphreys-Wetworth leads the National Suicide Prevention Strategic Initiative, provides subject matter expertise, and gives a range of counsel in policy, science, public health, and evaluation. As a licensed psychologist, she specializes in mental health promotion and suicide prevention efforts focused on the healthcare industry and veterans and military service members. She has led national efforts such as 988 state and territory planning, best practice and care transitions for individuals with risk of suicide, and state infrastructure for suicide prevention recommendation. She has over 25 years of expertise providing behavioral health services in remote, rural, and urban areas. Dr. Humphreys-Wetworth, thank you for leading today's webinar. I'm excited to hear everything you have to say. Thank you. I'm excited to be here. I have no disclosures, no conflicts or relationship issues that I need to report. Upon completion of today's webinar, I'm expecting that you're going to come away with being able to describe the elements of the Zero Suicide Framework, understand the evidence-informed interventions that exist for improving suicide risk identification, which means just uncovering the risk that's already there, and establishing a suicide risk management plan. And finally, identify resources that are available to support the implementation of zero suicide. So, suicide prevention is a big field. Why do we need to focus on healthcare? Well, studies show that people who attempt suicide visit healthcare providers in the week before they attempt suicide. More recent data shows us that of people who die by suicide, they had 16 health encounters in the year prior to their death. So, they were primarily seeing outpatient or specialty care. And these are opportunities where we could have uncovered their suicide risk and perhaps missed it. We also know that individuals with a serious mental illness die by suicide at a disproportionately high rate. Those with depressive disorders and bipolar disorders have a risk that's 25 times higher than non-clinical rate for suicide. And individuals who have schizophrenia, their rate is 20 times higher for suicide. So, our healthcare systems have a vital role to play in suicide prevention, and it's not just exclusively belongs to the behavioral health division or psychiatry. All healthcare has a role to play in suicide prevention. So, those are some of the things we're going to be talking about today. In 2021, the Surgeon General issued a call to action to implement the National Strategy for Suicide Prevention with two important key areas that focus on healthcare. One is to support the adoption of evidence-based care for suicide risk. Now, suicide risk can occur outside of having a mental health problem. And indeed, people die by suicide that have no mental health problems. So, it's important that we are looking at suicide care as a larger spectrum, and again, it's not just up to behavioral health or psychiatry to address it. Finally, we're also looking at enhancing crisis care and care transitions. So, increasing the opportunity for people to get connected with care in their communities, and that as they move from one care modality to another, like inpatient to outpatient, that that transition process is smooth, and we're going to be talking about that a little more later also. So, stay tuned. The Joint Commission has issued the National Patient Safety Goal 15.01.01 on reducing the risk for suicide, and this really outlines the best practices that we are looking for and that are supported by the Zero Suicide Framework. So, for example, the second one there, using a validated screening tool to screen patients. Asking a question outside of a validated screening tool does not meet this regulation. So, utilizing those quick, easy screeners that are available, we're going to talk about a couple of them today, to screen patients and identify their risk, and then if they are positive, we follow up with a suicide risk assessment. So, they're at risk, how at risk are they, and then utilizing that information to develop a suicide care management plan together with a patient. So, focusing on health systems saves lives. We have evidence across multiple health and behavioral health systems that when they engage in a comprehensive systems approach to suicide prevention, lives are saved. We see suicide events such as suicide attempts and suicide deaths go down when our entire health system is embracing this idea of zero suicide and that everyone, everyone has a role to play in suicide prevention within our health care system. It's not just the role of our clinicians. It's the role of everyone. So, the National Survey on Drug Use and Health also included information on serious mental illness, and in 2022, the most recent version that's out, it told us that about two-thirds of adults have serious mental illness and are receiving mental health services. So, about a third of them are not. So, we're looking at about 15 million people, a good five million are not receiving the mental health services, and our health care system can't reach them, but we can reach the two-thirds, the 10 million people who reported they have a serious mental illness. The same is true for those adults who reported they also have co-occurring disorders. So, they have a serious mental illness and a substance use disorder, and again, the stats are about the same, about two-thirds are in our care, and when they're in our care, it's an opportunity for us to uncover their suicide risk and try to understand what are their particular situations and how can we intervene and support them to move away from thinking about suicide and moving toward life and health and well-being. So, let's just talk about suicide rates a little bit. We know that suicide rates differ by race and ethnicity and by sex, as the Center for Disease Control and Prevention calls it. We see that the highest rate are among our non-Hispanic American Indian and Alaskan Natives at 28.1 per 100,000, and the lowest rate, according to the CDC, are among non-Hispanic Asians, 6.8 per 100,000. All deaths by suicide are tragic, and these numbers reflect people who have died by suicide. So, when I think about that and I think about the opportunity we have to save lives, it's important for us to know that there are certain groups of people who are more at risk because more of their people are dying by suicide than others. So, these are things to keep in mind as the person is in front of us. So, when we look at sex or gender, we see the CDC has 22.8 for males, 5.7 for females. That means men are dying by suicide at a four times higher rate than women. Women attempt more. Men die more because men use more highly lethal means, predominantly firearms. So, it's something to keep in mind as we continue to think about suicide and suicide rates. Also, age plays a factor. We know that these are the suicide rates, the most recent rates from the CDC, and the highest rate are among our oldest people. Those aged 85 and older at a 22.4 per 100,000, closely followed by our 75 to 84. So, our older elders or senior elders are dying at the highest rates and I think that surprises a lot of people. I think a lot of people think it's our young people, which it's our next group, our young adults, 25 to 34, dying at a rate of 19.5 per 100,000. So, there's no age here that we don't have to think about suicide. Even that age range 10 to 14, there are nine-year-olds and eight-year-olds who are dying by suicide. So, we can't eliminate it as an option just because they're young. We need to keep in mind that anyone can be at risk and we need to uncover the risk that's there. So, let's talk about some of these risk factors. These are the elements in a person's life that are associated with attempting or dying by suicide. So, just because you have some of these means your risk is higher, but it doesn't predict that you're going to die by suicide. I want to make that clear, but if these are present in your patient, it should perk up your clinical attention to dig in a little deeper and ask more about suicide and suicide risk. I think about hopelessness and I think about rage as like the two extremes of emotional continuum that suicide ideation could be walking in the shadow of those things. So, it's up to our health systems to shine a light on that shadow and help us identify when someone has suicide risk that maybe we've never talked about before. Additionally, I want us to think about how these risk factors start stacking up. We know that there's a shortage of mental health care professionals, so access to care is an issue. Crisis care in patient beds. I mean, 988 has been wonderful. It's expanded the reach of a number of people to be able to talk to someone in the moment of crisis, but still having a place to go is a challenge. We already talked about how people with serious mental illness have a higher risk for suicide. They're dying at a higher rate than others. We also think about the social determinants of health, stacking with a serious mental illness. Employment, finances, housing, all of those things plus their mental illness starts to weigh upon potentially this is contributing more to their risk of suicide, even independent of their mental illness. So, in 2017, the Interdepartmental Serious Mental Illness Coordinating Committee came together. It's one of those landmark moments in mental health in that this group of people came together. So, these are people who are living with mental illness, have a family member with a mental illness, experts in the field to write a federal action plan to better help people who have a serious mental illness. The third focus is really on this treatment and recovery and the recommendation that we adopt effective suicide prevention strategies within our health systems. So, both the VA and the Department of Defense should adopt a zero suicide-like model for suicide reduction and consider the ways that we can disseminate this to the public health system, which we've been seeing that happen over the next few years. So, I've talked about zero suicide a lot so far, but what is it? So, when we think about zero suicide, it really is a foundational principle that suicide deaths for individuals who are under our care are preventable. If they are in a health or behavioral health system, we have the opportunity to uncover that risk, to mitigate that risk, and to provide the care that the person needs, that we design our system with a zero mindset. Yes, it's aspirationally based, but some systems have been able to achieve it, so it is achievable. This is based on measurement-driven improvement using evidence-based clinical care practices. We involve the voices of people who've had experience with suicide, either directly themselves as attempt survivors or as family members or caregivers of people who have attempted suicide or died by suicide, and then we look at the entire system is accountable if someone that we're caring for dies, not the individual clinician, but really the system, and how can we design it for zero? How can we design it so that we are identifying, catching, and treating the zero suicide aspirational goal? If we're reaching for zero, there's a lot more we're going to do than if there's some other number that's acceptable. So, here's the zero suicide framework. These are seven core elements that help us understand the integrated approach to zero suicide. It's a holistic approach. It's a continuum, and it's part of continuous quality improvement. So, while this requires leadership within an organization to implement, we also believe you have to train your workforce, that we need to identify people who have suicide risk. We need to engage them in their treatment and in their care in a suicide-safe management plan. We need to provide them with treatment that's evidence-based. We need to transition them to other care in a particularly evidence-based way, warm handoffs, good follow-ups, ensuring that the person arrives at their next level of care, and we need to look at our measurements and improve our process with continually rotating around this circle so that we get better and better and better as an organization at caring for people who have zero suicide is our goal. So, here's the seven elements a little bit more clearly. Four of these are specifically focused on clinical care. The other three are administrative. So, here are the four that are really focused on clinical care, and these are the ones I'm really going to focus on today. We're going to be focusing on first identifying individuals who are at risk via comprehensive screening and assessment, engaging them in a suicide care management plan, providing the evidence-based treatment or interventions for suicidal thoughts and behaviors, and then transitioning individuals through care with warm handoffs and supportive contacts. So, let's dig into those just a little deeper. Identifying individuals with suicide risk. So, we believe that if we're going to identify people with suicide risk and we know that suicide risk can be independent of mental health, then we need to comprehensively screen people for suicide just as we take blood pressure every time we see a health care provider. Screening for suicide is another universal screening strategy that should be used in health care, and we understand that there are many types of screening that can be used. So, there are tools that are evidence-based, just like the Joint Commission talked about using those screening tools. There is the ASQ, so Ask the Suicide Screening Questions. This is one that's appropriate for ages 8 to 24, so it kind of gets at that lower, younger demographic. These are interview questions. It's available in multiple languages, and it's part of a toolkit. There's also the Columbia Suicide Severity Rating Scale, the triage version, right? So, that's the screening version. Generally, it has been developed with reliability and validity for ages 12 and older. It also is set up as interview questions, so questions you ask the patient that's in front of you and available in multiple languages. Then also, there's the Patient Health Questionnaire 9 or the PHQ-9. It's been used for a long time in health care settings. It is a self-report form, so it might be a piece of paper that you give the person to take or an online form that they complete. But really, the PHQ-9 is a depression screener, so eight questions are related to the diagnosis of depression. The ninth question is the suicide question, and so if we're not asking that ninth question, we're not screening for suicide. So, it's important that you think about carefully what screening tool you want to use and how it's going to connect with the rest of the services that you're going to be providing. As part of a clinical assessment with someone who has a serious mental illness, screening for suicide risk and conducting a suicide risk assessment when the screening is positive, you should include reviewing those risk and protective factors around suicide, which include the vulnerabilities around housing and around employment, financial support, available social supports. Remember those stacking factors that we talked about earlier? We know that patients with specific diagnoses have higher risk and those specific diagnoses interfere with their ability in some cases to successfully negotiate their outside world, meaning their housing and employment and relationships with others. So the presence of serious mental illness, past psychotic episodes or high risk for experiencing a psychotic episode also increases the risk of suicide ideation, attempt and death. Remember that we don't only screen those who have a mental illness, but if they do have a mental illness, we should be screening because it's a risk factor for suicide. So when suicide is on board, like it's positive and we've determined they are at risk, we want to engage them in collaboratively developing a suicide care management plan. When we do this collaboratively, now that means that the individual who's at risk, the patient or the client, they are coming up with things they can do to manage their distress and we are helping them walk through a process, a structured process of developing that care management plan and we know that when that happens, we have demonstrated high recovery rates and lower suicide attempts. So a patient care management plan involves a sequential series of strategies that the patient can use when they're feeling distressed. You might be familiar with the Stanley Brown safety plan or Craig Bryan's crisis response plan. Those are two good examples of a suicide care management plan that we can use and it all begins with the patient and you together identifying what were the original kind of warning signs that this crisis was coming on. Maybe it was arguing with their roommate a lot or maybe it was not sleeping well or finding that they're worrying all the time. Those are the kind of warning signs that when they come back, they're like can stop and recognize, oh, I'm headed for a bad place. I'm thinking that this might lead to thinking about suicide. So, ooh, what could I do instead? So we start with things that they can do to distract themselves all on their own, right? It might be going for a walk or places they could visit where they could be distracted, like a coffee shop. Our job as the clinicians are to help them generate those strategies, like encourage them to tell us more and then also to do a little reality check with them about those strategies. So for going for a walk, it's a great thing to do. You get outside, you get some fresh air, you get out of the house, good thing to do. But maybe it's not a safe thing to do in the middle of the night or in their particular neighborhood. So we need to ask those questions and ask them, when is a good time you could do that and where might you go and would that be safe and what time would be safe and where could you go instead, right? So if their coffee shop is Dunkin' Donuts and it's open 24 hours, that might be an okay solution or maybe their coffee shop closes up at 10 o'clock and doesn't open again till 5 a.m. What are they gonna do between 10 p.m. and 5 a.m.? So helping them think through those kinds of caveats to their plan and coming up with other things to fill in those slots is part of our role as the clinician. So then we look at, well, that's not working, what's the next step up? Well, the next step up in their suicide care management plan might be, who could they call to talk to? And then we write the person's name down and we write their phone number down and we generate that list. And then we say, okay, are these people you're gonna talk to about your problem or people you're just gonna hang out with and talk about other stuff? So if it's people they've identified they want to talk to about their distress and the problem they're having, we might want to take the opportunity to make sure that person is on board with being that resource. So we call them up, we dial their number and the person talks to them and says, hey, I'm working on this kind of plan for my care and I've identified you as one of the people who I can rely on when I'm in distress that I can talk to, you willing to do that for me? And we get their assent and so they go forward on the plan. We wanna know whether that person's willing now rather than later when the person tries to call them. So it's an opportunity for us to ensure that their network of safe people are willing to be part of their network of safe people. And if that person says, no, I got a lot going on in my life right now. I love you, I care about you, but I just can't be that person. Then we have a therapeutic moment to talk about it while they're still there with us, right? Okay, so the next step up from this, if talking to their friends or their family members isn't reducing their distress, they're still struggling. Well, then we go to the professional associations. That's us, that's the clinicians, who can they call? What are your after hours crisis numbers? 988, they can call 24 seven, right? So those are the kinds of things that we put in place there and then emergency, like if still distress, where can they go? Where's their closest emergency room? Can they call 911? Is there someone who can transport them? Those are the kinds of things that we want to focus on. And then once we have this plan, it can be a piece of paper that the person takes with them or they can take a photo of it with their phone, or it can be an online app on their phone. There are a million different ways that this person can have it with them and refer to it when they're in need. There's two other areas that as a clinician, I really want us to make sure that we include. And one is that when they were thinking about suicide, what was the method that they identified that they might use? And now that they're feeling a little better, what can we do to make sure there's some safeguards around that method, that if they're starting to feel distress, it's just a little harder to get and use that method. So is that a firearm? Is there someone who can hold their firearms when they're in crisis? That might be one of the people that they can call. Is there a way to lock up their firearms? Who could hold it for them until they're feeling better? Are there local resources for securing that? Or maybe it's medications. What are the medications we need to be thoughtful about in having an abundance and available? Maybe we need to think about other types of suicide methods, which we call lethal means, right? Lethal means or the methods that they may think about to put some safety and protection around that. And it's the method that they've identified, not the ones that we've identified. And it's okay to ask, have you thought about others if they come up with one? The other thing that is important that we can include here are what are their reasons for living? What are the things that give them hope? And those can be the things to help remind them of why they wanna live, of why they do not wanna take their own life. And so important for us to incorporate those because that helps the person reach for those things. So maybe I would never do that to my dog Sammy because there's no one else who would take care of him. Great, so we put Sammy on there as a reason for living. And if I'm his ongoing clinician and he tells me Sammy's sick, ooh, my little awareness should perk up like, ooh, that was one of his reasons for living. Maybe we need to be doing some protection around that or thinking about that. So those are some of the reasons why we do both of those things. One, to inspire the patient and also for us as a clinician to be aware of when some vulnerabilities may emerge around those reasons for living. Now we wanna talk about treating suicide thoughts and behaviors specifically using evidence-based treatments. So a person's mental illness and their suicidality may not be the same thing. They may walk in parallel. I've talked about how suicide can walk in the shadow of their mental illness. So we may be treating their depressive disorder and they might be getting better, but if we haven't also addressed their suicidality, it might still be there lurking in the shadows even though it looks like their mood's improving, we may not have addressed their suicidality. The same is true with medical conditions. Okay, so suicide can be in the shadow of their medical condition. And because we haven't thought about mental illness or mental health diagnosis in addition to their medical problem, we may not even think that that's an issue. And that's why we need universal screening for all patients, whether mental health, behavioral health is on board or not because we know some groups are more at risk. People who have chronic pain that is inescapable other than with medication and some very intricate interventions struggle with this idea of continuing to live and continuing to live like this. People who experience a social loss, loss of relationship is one of the biggest drivers for many people to think about suicide because it's so personal and so painful and you can't get it back once it's gone. You can try to replace it, but you can't reinvent that relationship. And for people who've not had experience with losing relationships, it can be absolutely devastating. So we wanna make sure that we are treating suicide loss directly and specifically using evidence-based treatment specifically for suicide. So some of these you're probably familiar with like dialectical behavior therapy or DBT. You also may be familiar with cognitive behavior therapy. There's a cognitive behavior therapy for suicide. There's also CAMHS, which is Collaborative Assessment and Management of Suicidality. And there's also a short intervention, a brief intervention called Attempted Suicide Short Intervention Program that all of these are evidence-based treatments. And all of these are appropriate for use when suicide is on board, regardless of what their mental illness is. You can use these approaches for addressing their suicidal thoughts and their behaviors. So let's talk about transitions. Care transitions can be really, really stressful for people who have a serious mental illness. Change is hard. Change is hard for all of us. You have to change a caregiver, someone you've shared very vulnerable, emotional, mental, personal things, and now you have to go see someone else. It's really challenging. And so holding that trust in your hands as you're helping them move to another provider, for example, moving from inpatient psychiatric care making sure that that process is very warm, it's very supportive, that we deal with the anxiety of changing providers upfront and we talk about it and we do things to mitigate that anxiety. For example, we find ways for them to meet the new provider and that might be a telephone call. I mean, in an ideal world, the provider would come and meet them on the unit, but that's just not possible in many, many, many cases. But maybe there's an innovative opportunity. One inpatient provider partnered with their outpatient provider who lived a long distance from the inpatient hospital and they were making referrals. And one of the things they did that was innovative to help reduce this anxiety, to increase this sense of comfort in moving to a new provider was they get a quick video. So the video was like, here's the site you're gonna be going to. And when you walk through the door, here's who you're gonna see. And this is Ellen, and Ellen's gonna take your information and help you with your paperwork, right? And here's the clinician you're gonna see. And there's a short video of the therapist, the clinician introducing themselves. And that brief innovative handoff process did a couple of things. First, it demonstrated that we care enough about you going to this new person that we want you to see them. We want you to understand where you're going and who you're gonna see before you leave us. And people loved it. They loved the opportunity to sort of virtually get to meet their clinician and it decreased their anxiety. So consequently they saw show rates dramatically increase and engagement in that next level of care. So we know that when these things happen, when people have warm handoffs, they're much more likely to show up in the next care provider's appointment. We know that getting that next appointment in a timely manner is crucial. There is this critical window that is emerging in the research. And that window is within two weeks, but actually it's looking more like seven days. That first appointment, first contact with that next provider within seven days of discharge from inpatient care makes an incredible difference on whether the person will reattempt or die by suicide and especially true with our youth. So it's important that we work closely with our referral source to get that first appointment or first contact as close to discharge day as possible. The other thing that helps with this process is something we call supportive contacts or caring contacts. Notes from you, the clinician who is handing them off to the next person just saying, thinking about you, hope you're doing well. Not asking them to do a survey, not asking them to call you, but just letting them know that you still care about them, that you want them to be doing well. And it can be a note in the mail, it can be a text on their phone. And these are things that can be set up automatically. So they go out and you don't have to remember to do it, which puts the burden on you as the clinician. It can be set up automatically within your health system so that it goes out and every patient gets it every time consistently across all your service lines. So those are the four areas that focus on our clinical care. But I wanna come back and talk about training. Training is an administrative element of the Zero Suicide Framework. And in order for Zero Suicide Framework to work, it means everybody needs to be on board, working together within their role to prevent suicide deaths. When we make a commitment to zero suicide, everyone understands that safe suicide care starts the moment they walk in the door. And it's essential that each staff person, each person in our workforce, from the receptionist to housekeeping, to social workers, to clinicians, to aides, everyone has a role and they understand their role. And we've trained them in their role and what components of safe care in suicide are translated into their role and how they can provide that warm and caring supportive atmosphere that helps people disclose that they're thinking about suicide. Because honestly, talking about suicide is a scary thing. There's lots of things people are hesitant to disclose. And if you think just a moment, you can probably think of quite a few that you might be hesitant to disclose to someone you just met or to a healthcare provider. And suicide's just one of them. So when we take a systemic approach to making it safe to talk about it and to deal with it and heal from it and prevent it in the future, it just relieves that anxiety and helps the person really engage in all of their care. So at our Zero Suicide Tool Institute, we have the Zero Suicide Toolkit. The toolkit is available online, it's free. These tools and resources are available for you. We expect you to go on and try them out. You're gonna see outcome stories. There's gonna be tools and readings and videos. There's webinars and podcasts. And it's right there at zerosuicide.com. Additionally, if you're wanting to get started in zero suicide, we've developed a number of 11 steps that you can take. And there's a quick start guide here for you to take a look at it and begin looking at some of these steps. One of the first things we encourage people to do is to pull together an implementation team from different departments within your organization. So your healthcare clinicians certainly are part of the team, but you need your leadership on board because for a system to say, we are going to be a zero suicide organization, we're gonna focus on zero as our number, that really needs the support of leadership. It needs the support of administration. Certainly our clinical staff, our support staff, our peer service staff, but also our legal and risk management folks need to be on board, our quality assurance people, information technology, if we're gonna be embedding things in the electronic health records, then we're gonna need this whole team to come together and have people at the table with the staff, people who have lived experience and can talk about what it's like in a facility like theirs, where maybe they've had a good experience or maybe they haven't had a good experience and to make sure that that does not get translated into your organization. Additionally, we have a couple of resources for you to try out. One is your organizational self-study. This is your organization's opportunity to say, where are we at? Some things we're doing really well and some things we have some growth opportunities on. So you complete the organizational self-study. It can be done in a variety of ways. You can have your implementation team, each member of it, take it, and then you compare the results from all those different perspectives. You could come together and go through it and come to a consensus agreement on where you think the organization is at. Maybe you wanna send it out to department heads and have them complete it and then compile the results. There's a variety of ways you can do this self-study to get an understanding of where you're at right now as you begin this process and to build then in your goals and your strategies and the things that you need to be thinking about as you move forward with the Zero Suicide Framework. Additionally, we have a workforce survey. So this is for your staff to tell you how comfortable they are in working in suicide prevention. I will tell you, most clinicians have not been trained in suicide care. We see it as a gap in a number of clinical training programs. They may do a little bit, like a couple hours of one class, but they really don't get the training that they need in providing high-quality suicide care. So the workforce survey helps all staff at all different levels within your organization tell you their own comfort and readiness, and that gives you information on what kind of training you may need to bring on board or where you may need to start. Finally, we also have a Zero Suicide Outcome Studies. So these are case studies that have been published of organizations who have used the Zero Suicide Model. When they use a systemic approach to zero suicide, which is the Zero Suicide Framework, you see reductions in suicide deaths. More lives are saved by using this framework. We also see decrease in repeat hospitalizations. We see improvements in screening rates because they're following a particular protocol and everybody's been trained on the protocol and there's a place for it in the medical record and there's an alarm if it didn't happen. We also see that there are fewer repeat attempts and we see better compliance of people recovering at a higher rate from the illnesses that brought them in and from the suicide rates are going down. And there's cost savings. When everyone is moving in the same direction, it's less expensive. We have a network available for anyone to join. You can sign up at zerosuicide.com. It's our listserv. This is an email listserv. It's a moderated listserv where people can post their questions about implementing zero suicide or specific pieces of zero suicide. They can ask their colleagues who are implementing, how have you tried this? Or we're getting this pushback from our leadership. How have you approached it? And you can get feedback on the activities that you're implementing, how you have incorporated certain things into your EHR, what others are finding with research. And we get those articles posted to the zero suicide listserv. It's free. You can sign up. So finally, you can use the Zero Suicide Toolkit. It's here and available for you. It's free. We're excited. And it has much, much more in it than I've been able to cover today. I've just been able to give you kind of the highlights about what is involved in our Zero Suicide Toolkit. So here's the bibliography of the citations that I talked about today and the resources that can help you with some of the things that we talked about, some of the links and additional resources and tools for you to use. Thank you. This is such an interesting presentation and highly needed. So thank you for everything that you said. Before I shift into Q&A, I want to take a quick moment and let everyone know that SMI Advisor is available from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete a mental health rating scale, or even submit questions directly to our SMI expert. It's as easy as downloading the app. It's smiadvisor.org forward slash app. So now we're going to move into some questions. I'm going to I'm going to start the question portion from questions that are maybe simpler and I'm going to move into the little more complex ones. So the first question is, in my personal experience, I work in an FQHC and there's many times where a patient comes in, the PHQ-9 is really elevated, maybe to on question number nine, that form is given to the medical provider and oftentimes the patient doesn't hear back from someone or the medical provider doesn't doesn't provide any kind of recommendations. What is your suggestion for something that happens in a system just like that one? Okay. Thank you. So best practice is they have screened positive, right? So if they are positive for suicide, then immediately we need to go into a suicide risk assessment. They should not leave without getting that risk assessment completed. There are a number of tools that your physicians can use to do that risk assessment and to do an expedited warm handoff to a clinician that day, right? So they don't have to go to the emergency room. They can go to an urgent care clinical appointment. So those are the kinds of systems that I would be thinking about if suicide is not on board for the person, but they are looking at a serious depressive episode. They still need to see a clinician right away because as we know, major depression and suicide can walk in its shadow, even though they maybe didn't want to disclose it that day or disclose that it wasn't that much, but any positive, any positive response to suicide ideation is a positive screen. And we need to explore that a little more. Right. Yeah, there's big systems and sometimes things fall through the crack, but there's no excuse for not assessing. So if anybody's on this call and they have the number of the clinic they attend, you can always call, ask for behavioral health, but make sure to let your voice be heard. So the other question follows the first one. How do you encourage clinicians on the call, family members, anyone who knows somebody who's struggling with the idea of suicide to have these conversations? Oftentimes people are afraid to say, you know what, are you suicidal? Do you have a plan? What do you suggest? So I suggest like warmups, right? So a warmup is commenting on what you've observed. Like why are you concerned? So something like you seem really down lately. I'm really concerned for you. What's going on? Opening up the conversation a little bit. And then as you listen to them very carefully, you say, you know, sometimes when people are feeling this down, they think about ending their lives. Are you thinking about that? Right. So you may not have to just come out and say, are you suicidal? You can, you absolutely can. But say it in a warm and compassionate way. Are you thinking about suicide? You know, I care about you. I'm worried about you. And if your gut is saying yes, they are, even though their words are saying no, which one do you trust? Your ear or your gut? You trust your gut because there's a lot more going on there that the person is trying to tell you, but has hesitancy in telling you that. So you may need to do a little more education around, you know, lots of people think about suicide and there's really good ways for people to get help without having to be shipped to the state hospital. There's ways they can be helped, you know, today, you know, 9-8-8 is an option. How about we just call them and see where it goes and you dial 9-8-8 and you put the speakerphone on and away you go together. And my personal experience that empathetic approach and asking them in a way that they feel like it's not invasive, but welcoming, and you come up with a plan together, as you mentioned, calling somebody and so forth and so on. So a few other questions. So we have some, one of the attendees is asking, how is suicide prevention different with the LGBTQ plus youth? Is there any difference you would identify? With our LGBTQ youth, we're thinking about their social circles, the environment in which they are living and operating. Do they have support for being LGBTQ or not? Are you the first person they've told? What are the supports that they're going to need in order to navigate just as a straight person would need that? We do have sensitivities around that because of the discrimination, because of the social stigma that still exists systemically around people who are, quote, different and whatever that different is, that helping wrap that social support around them and being a resource for them. Yeah, I could keep going, but I'm going to pause. For sure. For sure. There's obviously different variances, but exactly what you mentioned. So I have two other questions that are going to follow up the initial one. The next one is, you have someone you saw and they, let's say they screen positive for the PHQ-9 or Columbia, they attended a session, but for whatever reason they didn't do a follow up and we're considering depressive symptoms, right? Lack of energy or desire to follow up. Do you recommend scheduling a follow up without consulting the patient just to check up? Or do you expect, or should we expect the patient to call us back? Oh, I don't leave it on them. If I have clinical concerns, I'm going to be reaching out and working to get them in. Because remember what depression does. Depression shuts down our sense of worthiness. And when a clinician calls you and say, I'm really concerned about you. I want you to come in. I think, I think I can really help you. You're valuable. It makes such a difference. I would not just leave that off on them. I would, I do some outreach. If there's a mobile outreach team, if I have a case manager, I'd be leveraging whatever tools I have to be able to reach out to that person. Especially if we're looking at a positive suicide screen, I don't leave that. Especially with the, with the high index that you mentioned earlier, there's a lot of people being screened. I personally put a little reminder if somebody missed an appointment to say, okay, to call this person in two days. I don't reach them. I'm trying again in about two more days. So I totally agree with you. Absolutely. Absolutely. Yeah. In that hour, they didn't show up. We can call them. Right. Yeah. Something happened just to make sure there's their services intact in place. So let's talk a little bit of telehealth here. So you mentioned interventions. How do you use that platform of telehealth to make sure that when we do interventions, we're doing assessment, they're, they're as good and as appropriate as when we're seeing somebody face to face. Okay. So COVID really launched us all into doing telehealth much more quickly than I think the field would have grown. What we find with telehealth is many people really like it. They really like being able to be in their bedroom and have a conversation or, or be in their workroom or their kitchen or their dining room table, rather than having to go out and go to a clinical office, the things around telehealth that we need to think about are we need to think confidentiality on our side, right? We need to be in a quiet, safe space. And so do they. So having those conversations about how telehealth is different than inpatient and that informed consent that goes around providing clinical care through telehealth. So when we think about that, there are some best practices, right? So getting informed consent, talking about the pros and cons of telehealth versus in-person sessions, encouraging them to find that quiet, safe space. Like you don't want to do this on a coffee shop. You want to do it someplace where you feel comfortable. And in my office, sometimes people bring people with them to their session, like youth may bring a parent. And so if it's okay, we see everybody together. It can be the same in telehealth, but again, it has to be informed consent. You have to talk about what that looks like and kind of do those things upfront, especially if you're dealing with kiddos through telehealth. You want to have an understanding with the parents about where the lines are and who's going to be in the room at the time of the conversation. Have you had any experiences where the patient says, yes, I have a plan and no, I do not want to go to the hospital or I don't want to seek support services. And if so, what strategies do you have to compliment that, the structure of telehealth? It's scary, isn't it? Sure. So that's the time when you really lean in and you say, well, well then tell me what's going on. And you use all of your clinical de-escalation skills, where you're focusing on really listening to them and really aligning and understanding where they are and what they're needing and who is around to help them. Maybe they don't want to go to emergency room. Maybe they don't want law enforcement to come, but who could come and can we call them right now? Who could be with you? And if there is no one, if you feel like it is imminent, then you have some responsibility to helping them, to saving their life and thinking about that in terms of your organizational protocols around telehealth and around intervention. If there is a mobile crisis team, so a mental health who can go there, much better than law enforcement coming in, which we will use if we have to, but we want to preserve the clinical relationship as much as possible. Right. And just letting them know also that this is hard for you as a clinician to assess that. I have a few other questions before we close out. It's the preparation that we can offer the individual who potentially may be experiencing thoughts of suicide or maybe a plan. Do you recommend doing some kind of role play with them? For example, I'm the patient who has the ideation and you're the provider that you and I can role play. Me having a conversation with somebody who may support me later down the line to be a little more proactive or something along the lines of that, because I know it's really difficult for people to say, you know what, I am suicidal. I have these thoughts, but I'm feeling like they're going to judge me at the same time, kind of pushing to the side. Absolutely. The more skills and tools we can put in their tool belt for coping, the better off. And so role play is a great way for them to sort of, how can I get the words out of my mouth and how can you respond to that? And I can see how that would feel. And then the patients in the role of coach, oh no, she wouldn't say it that way. She would say it this way. And you can, you know, rewind and try it again with how that person might say it. And they get the opportunity to say those things out loud to their clinician in practice for saying it to someone else. So then when they do say it to someone else, it's much more natural. And they can even have their little scripts, like if they're going to call somebody, they can have it all written out, ready. We do that for people who have anxiety, right? They have a little script, you know, they're nervous about calling someone and confronting them. Well, they have their script of what they're going to say and what they're going to do if the person does this. Those are all the things that you would work with that patient on and build up their skills and their tool belt and their readiness. And then, you know, have them call you afterwards, how'd it go? Debrief it with you. And if it went well, great. And if it didn't go so well, then talk about it. Where did we miss it? What can we do better next time? And then schedule a follow-up session and try it again. Right. I think that's a really powerful intervention because we always focus on the risk, but we don't focus on the follow-up. In some sense, preparing somebody to have these conversations is as powerful as the intervention itself. Even putting it on the fridge with the numbers, who to call, having an ideal plan, I think is ideal. Okay, last question for you. One of the participants is asking, how can they implement your whole structure within an agency? Is there an approach to start maybe with one person, a small group? Does it go from the CEO, bottom down? Any suggestions on that? Absolutely. So when you're thinking that, wow, this is something we should use at our agency, I would encourage you to dig in and learn more. So go to the website, learn a lot more about it. And then consider who's the best person to champion this. Maybe you are the champion in your organization to get it going. Maybe there's someone else who you know could be an ally and an advocate and maybe has a position of leverage and power. Get them on board. And then you start going to leadership and saying, hey, this is why we should do this and have it all laid out and begin educating them. Remember that change is hard. Organizational change is hard and that people resist change. But even when they resist it, if they can see the benefit of it and that there are little steps you can start doing, like putting a committee together to look at it and explore it. You're not fully committed to it yet, but where are we at? And doing that organizational self-assessment is one of the things that kind of lights up and helps leadership see that we could be better. That's fantastic. So thank you so much for doing this fantastic webinar. I know there's tons of information that you still can share with us and we could spend a whole bunch of hours. And thank you for answering all the questions that we all had because some of the questions were mine. Before we close, I'm going to have I'm going to share a few announcements so we can move on to the next slide, please. So if there is any topic covered in this webinar that you would like to discuss with your colleague in the mental health field, post a question or comment on the SMI Advisor Discussion Board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. If you have a question about this webinar or any other topic related to evidence-based care for SMI, you can get the answer within one business day by one of our national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators or anyone else in the mental health field who works with SMI. This is completely free and confidential. SMI Advisor offers more evidence-based guidance on wellness, such as the webinar ZIP Code and Mental Health, Where You Live Matters for Individuals with Serious Mental Illness. This webinar provides a general overview of the ways that social environment impacts mental health among individuals who live with serious mental illness, including psychotic disorder. Access the webinar by clicking the link in the chat or by downloading the slides. To claim credit for today's webinar, you need to have met the required attendance for your thresholds and your profession. After the webinar ends, please click Continue to complete the program evaluation. The system then verifies your attendance for claim credit. This will take up to one hour and can vary based on your local, regional or national web traffic using the Zoom platform. Last slide, please join us next week on February 23rd as Dr. Deborah Pinos presents Bridging the Legal and Clinical Interface for Justice Involved Individuals with SMI. Again, this is a free webinar and will take place next Friday, February 23rd, from 12 to 1 p.m. Thank you all who participated. Thank you for the great presenter and until next time. Thank you so much.

Zero suicide

Systems approach

Suicide prevention

Healthcare

Dr. Teresa Humfrys-Waughworth

Risk identification

Care management plan

Telehealth

Evidence-based interventions

Core elements