AtlantiCare Health System started Zero Suicide implementation in 2015, driven by internal data indicating only 50% of individuals discharged from the inpatient psychiatric unit attended their first scheduled outpatient follow-up appointment. To address this, a new suicide prevention protocol consisting of a bundle of interventions was developed to improve patient engagement.
- From April 2017-March 2018 all patients discharged from inpatient psychiatric care who participated in the protocol were offered an outpatient follow-up appointment within 48 hours, and 100% of those same patients attended that appointment.
- Only 9% of patients who completed the protocol were re-hospitalized at the inpatient psychiatric unit, compared to 22% and 30% of patients who did not complete the full protocol or declined involvement in the protocol, respectively.
Zero Suicide Implementation
AtlantiCare, a member of Geisinger, is an integrated system of services designed to help people achieve optimal health. It includes AtlantiCare Regional Medical Center, AtlantiCare Health Engagement, the AtlantiCare Foundation, and AtlantiCare Health Services. Its more than 5,800 employees and over 900 physicians serve the community in nearly 100 locations. AtlantiCare is committed to becoming a suicide safer health system and has adopted the comprehensive Zero Suicide philosophy, framework, and resources to improve care and outcomes for individuals wherever they receive care in the AtlantiCare Health System. The impetus to adopt the Zero Suicide framework in 2015 was driven by data that indicated an increase in suicides and suicide-related events in the communities in which AtlantiCare provides health care services. Consequently, the opportunity to positively impact individuals who may be at risk for suicide aligned with best practices was identified as an AtlantiCare Health System priority. A dedicated and inter-professional Suicide Prevention Team was chartered and is led by our chief medical officer.
Highlights of AtlantiCare’s system-wide approach include implementation progress in each of the seven elements of Zero Suicide.
- Focus in the Lead element included participation in the 2015 Zero Suicide Academy hosted by the National Action Alliance for Suicide Prevention. We administered the Zero Suicide Workforce Survey, completed by over 2,600 staff across the AtlantiCare Health System, to assess staff knowledge, practices, and confidence in providing suicide care. We also administered the Zero Suicide Organizational Self-Study to all AtlantiCare clinical areas to assess what core elements of safer suicide care were currently in place.
- Trained 90 behavioral health clinical staff on Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) through the Beck Institute, provided education by nationally recognized experts on Zero Suicide to 100 AtlantiCare medical and clinical leaders, and also deployed suicide prevention e-learning to all AtlantiCare staff.
- Designed a standardized Suicide Prevention Plan that includes best practice tools and algorithms and implemented standardized tools, including the Patient Health Questionnaire (PHQ-2+1) and Columbia Suicide Severity Rating Scale (C-SSRS), to better identify clients at risk for suicide.
- Designed an initiative to promote access to care through multiple clinical sites, improved timely access to care and frequent contacts, and collaborated to meet individual client needs to promote engagement.
- Deployed standardized tools and approaches, including collaborative safety planning, Counseling on Access to Lethal Means (CALM), and CBT-SP to provide treatment.
- Designed a protocol to engage and support clients at risk for suicide, and hired a dedicated Suicide Prevention Coordinator to provide outreach and support for identified high-risk clients to facilitate regular contact and care linkages.
- Coordinated a system-wide effort to collect and analyze data across multiple electronic health record platforms in order to gather actionable information.
Engage and Transition: Implementation of the Suicide Prevention Protocol
A key focus area for the initiative involves clients who transition from our psychiatric inpatient unit to outpatient care. Research indicates that suicide rates are high among individuals at risk for suicide in the transition period immediately after inpatient hospitalization.1 Correspondingly, our data indicated that only 50% of clients discharged from our inpatient psychiatric unit attended their first scheduled outpatient appointment. This was the case even though historically AtlantiCare has offered follow-up outpatient appointments for all psychiatric inpatients within seven days of discharge. While the 50% show rate did not segment the client population according to suicide risk level, we noted it as a clear opportunity for improvement in the engagement and transition of at-risk clients.
In response to the need to improve the engagement of individuals identified as at-risk for suicide, and to bridge key transition points in care, AtlantiCare developed and implemented a new suicide prevention protocol (protocol) led by a dedicated Suicide Prevention Coordinator (Coordinator).
- The protocol is a voluntary service for adults and youth referred from AtlantiCare clinical areas, including the inpatient psychiatric unit.
- The Coordinator provides outreach and support to clients enrolled in the protocol who are identified as high risk based on an initial Columbia-Suicide Severity Rating Scale (C-SSRS) level ≥3.
- The primary focus of the protocol is on the safety and engagement of the enrolled clients. Safety is reinforced with the development of the client-focused collaborative safety plan, including key details regarding supports, triggers, coping strategies, means reduction, and the continuity of care plan.
- Client engagement by the Coordinator includes regular contact, the facilitation of timely linkage to follow-up appointments, ongoing C-SSRS reassessments, coordination with providers, and assistance with navigating community resources.
- Cognitive Behavior Therapy-Suicide Prevention (CBT-SP) is an evidence-based practice and has been adopted by AtlantiCare as an integral component of care for clients enrolled in the protocol and for all clients who are assessed as at-risk for suicide.
As noted above, a key area of concern involved high-risk clients transitioning from inpatient to outpatient psychiatric care. Since providing at-risk clients quick access to care following discharge is critical at this transition point, our prevention program includes a designated staff member who is able to provide same day/next day access for this at-risk population.
“We believe the improved show rate for the first outpatient appointment post-discharge for clients in our protocol is a significant outcome.”
Suicide Prevention Protocol Outcomes
In the period from 4/1/17 to 3/31/18, 26 clients were discharged from our inpatient psychiatric unit who were identified as at-risk of suicide and who consented to participate in the protocol. One hundred percent of those clients were offered an outpatient follow-up appointment within 48 hours of discharge, and 100% of the same clients attended their initial behavioral health follow-up appointment post-hospitalization.
Client engagement and appointment show rate are favorably impacted by several strategies, including the following:
- Coordinator interacting with the client at the inpatient psychiatric unit prior to discharge
- Inpatient staff providing education and information about the protocol before the client is discharged
- Frequent contact by the coordinator post-discharge
- Coordinator assisting with the navigation of care
- Coordinator contacting the client and/or designated support person when appointments are missed
- For clients referred to our Acute Partial Hospitalization program, transportation to services on day of discharge
While our baseline data did not segment the population of clients discharged from our inpatient unit by suicide risk level, we believe the improved show rate for the first outpatient appointment post-discharge for clients in our protocol is a significant outcome.
AtlantiCare has defined parameters to identify and track clients who have successfully completed the prevention protocol. Completion of the protocol requires participation in behavioral health services in partnership with the involved providers and at least 3 months of weekly C-SSRS assessments at a level of ≤ 2.
For clients referred from the AtlantiCare Inpatient Psychiatric Unit and who consented to participate in the protocol, significant results were achieved in several areas compared with those clients who declined to participate at all in the protocol.
Patients Discharged from the Inpatient Psychiatric Unit
C-SSRS Level ≥3
April 1, 2017 to March 31, 2018
(N = 56)
Completed per Protocol
(n = 12)
Partial Protocol Completion
(n = 14)
(n = 30)
Average Initial Admission
|% Attendance at Initial Follow-Up Appointment Post-Discharge||100%||100%||47%|
% Re-Hospitalized at Inpatient Psychiatric Unit Post-Initial Hospital Discharge
(within reporting period)
As indicated in the above table, engagement in the prevention protocol with the Coordinator appears to result in some positive outcomes for clients identified as at-risk. However, the data also alert us to the number of at-risk clients who either did not complete the protocol or who declined to participate entirely. The high percentage (30%) of at-risk clients who declined the program and were subsequently re-hospitalized indicates further that this subset of clients continues to experience severe psychiatric problems.
Given anecdotal feedback from clients and staff, current improvement plans are focusing on individualizing elements of the prevention protocol (e.g., less frequent contacts, alternative interventions to missed appointments) to potentially better engage clients who may feel the current elements of the protocol do not match their needs.
- Inua Momodu, MD, MPH, MBA, DFAPA, DFAACAP, Chairman, Department Psychiatry, ABH Medical Director
- Julie Drew, LCSW, MPA, System Executive Director – Behavioral Health
- Michael Saynisch, PhD, Senior Director, Social Services
- Angelo Adson, MSS, MLSP, MBA, LCSW, Senior Director, Clinical Services
- Gloria Seel, LCSW, LCADC, MAC, Senior Director, Addiction Services
- Lenore Hildebrandt, MEd, Director, Quality Management
- Trish Helms, MS, Director, Information Management
- DJ Schrag, LCSW, Director, Adult Outpatient
For more information contact Julie Drew at firstname.lastname@example.org.
- 1. Boyer, C. A., McAlpine, D. D., Pottick, K. J., & Olfson, M. (2000). Identifying risk factors and key strategies in linkage to outpatient psychiatric care. American Journal of Psychiatry, 157(10),1592–1598. Retrieved from http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.157.10.1592