The Betty Hardwick Center started its Zero Suicide implementation in 2017. Our primary focus was engagement in treatment after a crisis event, reduction in psychiatric inpatient hospital admissions and readmissions, and reduction in deaths caused by suicide in our client population.
- Developed a Pathway to Care track for those clients at risk as identified by the Columbia-Suicide Severity Rating Scale (C-SSRS). Clients are referred to this track after a crisis event.
- Strengthened our continuity of care and follow-up for those clients transitioning from a hospital or a crisis event to outpatient care. Our data shows an 8% decrease in hospital admissions from FY 2017 to FY 2018 for a savings of $23,400.
- Started tracking data regarding enrolled clients’ causes of death. The suicide rate was reduced to zero in 2018 and has remained so to date in 2019.
About The Betty Hardwick Center
The Betty Hardwick Center is a community mental health center located in Abilene, Texas. We have been in operation since 1971. In our catchment area, our center oversees and provides services for adults and children identified with mental health needs and intellectual and developmental disabilities for a five-county area in rural West Texas. On average, 1,400 adults and children receive mental health services per year. We serve clients without any ability to pay or who can benefit from services on a sliding scale, as well as those with private insurance, Medicaid, and Medicare.
We have more than 190 employees at the center as well as a rural office in one of our outlying counties. In the counties without a rural office, we provide monthly medication clinics in various locations in the community. In addition, we also provide psychiatric services to inmates in the county jails who are identified with a need for psychiatric medications. The Betty Hardwick Center has specialized caseloads targeting high-risk offenders as well as assisting prison inmates with reentry to our communities. We have programs providing services to veterans and their families, including counseling and support groups.
Zero Suicide Implementation
Before the actual implementation of Zero Suicide in 2017, a Zero Suicide Team was developed, and they were responsible for the overseeing the implementation, writing the policy, training existing staff, and doing follow-up. Members of our Critical Incident Stress Management (CISM) Team were also a part of this team.
Prior to implementation, we had made changes that positioned us for a smooth transition into the Zero Suicide framework:
- All mental health division supervisors and team lead staff attended the Zero Suicide Academy.
- The Columbia-Suicide Severity Rating Scale (C-SSRS) was incorporated into the assessment tools used by our Mobile Crisis Team and into our continuity of care hospital discharge planner.
- Three counselors were trained in Cognitive Behavioral Therapy-Suicide Prevention.
- All mental health direct care staff and program supervisors were trained in the Stanley and Brown Safety Plan, and we changed our safety plan to this model.
- Our center started collaborating with Mental Health America of Abilene to begin Local Outreach to Suicide Survivors (LOSS) training and to start a LOSS group.
The Betty Hardwick Center implemented the Zero Suicide framework in 2017. Our center was interested in decreasing rates of hospitalizations and readmissions to psychiatric facilities and increasing engagement in outpatient treatment upon clients’ release from psychiatric facilities. To address these concerns, we made system wide changes to implement the Zero Suicide framework. Some highlights follow:
- In 2017, all mental health staff were trained in the Zero Suicide framework as well as the C-SSRS, including all program managers, medication clinic staff, and front desk receptionists. This training is ongoing and is also part of a new employee’s training upon being hired.
- We designed a special subunit for clients who are identified as high risk for suicide and placed on our Pathway to Care. These clients may have recently been in a crisis, utilized crisis services, been a patient in an inpatient psychiatric hospital, or just reported symptoms to staff and scored high on critical questions on the C-SSRS. After any of these scenarios, the clients enter the Pathway to Care, which includes higher intensity services, such as weekly face-to-face meetings with case managers, safety plan reviews, and a C-SSRS screening at every meeting. Clients on the Pathway also receive extra support in removing barriers that may hinder their engagement in treatment, such as transportation, housing, and food. Being in this exclusive subunit not only allows case managers and physicians to better monitor clients for safety, but also promotes higher client engagement with services.
- As part of our new employee orientation, all mental health staff are trained in CALM (Counseling on Access to Lethal Means), ASIST (Applied Suicide Intervention Skills Training), and/or ASK (Ask about Suicide). As part of our Zero Suicide rollout, we implemented a three-year mandatory ASIST/ASK refresher for all staff. We provide ongoing training to case management and crisis staff on assessing crisis and administering the C-SSRS.
- The Zero Suicide Team meets quarterly. During this meeting, we talk about clients enrolled in the Pathway to Care, any barriers that have been identified, and success stories. We also have licensed staff conduct a quarterly audit of Pathway to Care charts to monitor services and compliance with the protocol. The Zero Suicide team then reviews the audit to identify successes, trends, etc. that need our attention.
Pathway to Care
As described above, our Pathway to Care is a case management track in Mental Health Services that provides more intensive services to those clients with identified suicidal risk. Our total number of clients served in Pathway has increased over the years, which means that more of our clients seen in crisis are getting the intensive follow-up they need.
Number of Clients Served in Pathway
|Year||Number of Clients on Pathway||Date Range|
Hospital Admissions and Readmissions
Our data show an 8% decrease in hospital admissions from FY 2017 to FY 2018 for a savings of $23,400. In the first three quarters of 2019, we had significantly fewer hospitalizations compared to the same time period in 2018. This could be the result of several factors:
- Greater engagement upon discharge
- More intense service provision in Pathway to Care
- More effective safety planning
Regarding hospital readmissions, our quarterly outcome measure is ≤ 0.3% for the year. The following chart shows the average number of clients who were readmitted throughout the year and the yearly percentage. The 2019 statistics are for the first three quarters.
Hospital Readmissions (Goal: ≤ 0.3%)
*First 3 quarters of 2019
In 2017, patients who were discharged from our local inpatient psychiatric facility were contacted on the day of discharge to increase engagement in outpatient services. In 2019, we continued our focus on clients being discharged from the hospital but also began to focus on crisis follow-up. We have face-to-face meetings with clients not already enrolled within 24 hours of a crisis event. These meetings ensure that clients know about our services and their treatment options, can enroll in services, are told when their appointments are, and receive follow-up contacts after missed appointments. From the statistics, it seems that our initiative and follow-up to a crisis have led to a decrease in hospital readmissions from last year. We will continue to focus on this area.
Deaths Attributed to Suicide
Deaths are documented for all clients enrolled in services if we are notified. In FY 2018, after implementing the Zero Suicide framework, we observed that there were no client deaths attributed to suicide. There were also no suicide deaths in FY 2019, Q1 and Q2, although, there was one “unknown.”
What We Have Learned and What’s Next
As part of our focus on continuity of care, we are trying to decrease our no-show rate. Bridging services for people seen in crisis and those who were hospitalized back into outpatient treatment post-discharge helps with this. Our no-show rate for clients coming to their first appointment had been consistently at 40%. This no-show rate included, but was not exclusive to, individuals seen in crisis, referred to intake post-discharge from the hospital, and referred to the center in general. Within the last quarter, the no-show rate dropped significantly to 25%.
Soon, we will be a Certified Community Behavioral Health Center. As such, we will be implementing a different type of clinic scheduling. We hope this new scheduling will reduce our no-show rate even more because clients’ appointments will be closer to their discharge from the hospital.
In addition to Pathway to Care, we have a licensed professional counselor who is certified to provide Cognitive Behavior Therapy-Suicide Prevention to all clients who enter the Pathway to Care. This is a structured therapy that focuses on identifying triggers, impacting psychosocial factors, and improving coping skills.
Our readmissions to inpatient psychiatric facilities have persisted, despite our increased aftercare and continuity of care services. However, our admissions have decreased. We will continue to work with our hospitals to determine a good aftercare plan but to also ensure clients’ stays are long enough for their symptoms to stabilize.
In order to focus on continuity of care and engagement with our clients in crisis and those hospitalized, we designated two positions: a Relapse Prevention Specialist and a Continuity of Care Coordinator.
The Relapse Prevention Specialist will:
- Contact clients seen in crisis within 24 hours, engaging them face-to-face if possible
- Enroll clients seen in crisis in ongoing services (e.g., case management, medication management, skills training) or, as a minimum, in short-term services to access community services and support
- Look through hotline logs and contact callers in need of follow-up on the next business day
The Continuity of Care Coordinator will:
- Work with hospitals to discuss discharge planning and coordinate an aftercare appointment with the Betty Hardwick Center as part of the client’s discharge plan
- Evaluate the client’s needs at the aftercare appointment and determine the most clinically appropriate aftercare plan
- Work with clients who are in our local inpatient psychiatric facility before the day of discharge to explain our services and set up an aftercare appointment
Implementing Zero Suicide has led to system wide improvements in many areas. Because we made changes at the organizational level to help serve our clients with mental health diagnoses, we have been able to identify areas that still need monitoring and improvement. Therefore, we will continue to do the following:
- Provide newly hired Case Managers with mental health intensive training in the C-SSRS and the Pathway to Care and Zero Suicide frameworks. Not only the training, but the rationale behind it, is helpful to case managers. It is also helpful for them to know the scope of this initiative and why we have the Pathway. The training has raised awareness of the need to ask about suicide every time.
- Address issues such as prejudice and discrimination associated with mental illness, which will hopefully make it easier for people to reach out and engage in services. In our work with clients, we sometimes encounter a barrier or a stigma to reaching out for help. With our initiative, we can engage more effectively with the clients in our services, have more honest conversations about suicide, and, in most cases, reduce the risk of suicide and a crisis event.
- Audit charts to monitor client progress and protocol compliance. This auditing also helps us monitor trends, look at the connection between service provision and progress, and identify any training needs our staff may have.
- Provide intense follow-up to those clients seen in crisis. Our clients need to know we care and that we are here for them. After a crisis event, clients are often embarrassed or ashamed or, in some cases, are picking up the pieces of their lives. With our more intense service track (Pathway to Care), we can support them through whatever they are facing. We also have peer providers who can help clients navigate life by sharing lived experiences.
- Engage with and provide intensive aftercare services to clients being discharged from inpatient facilities back to outpatient treatment. The first 24 hours after a hospitalization is critical for preventing suicidal ideation and behavior. With our follow-up services, we can be there for the client, monitor them, and assist them if needed. We have a 12-bed respite facility for short-term stabilization, monitoring, and support.
- Administer C-SSRS assessments upon admission to outpatient services after clients are discharged from an inpatient facility and/or anytime someone is at risk for suicide. This is the heart of our training. We need to ask about suicide every time it is appropriate so that we can help identify clients at risk.
- Provide continuity of care services to those clients who have been hospitalized for any length of stay.
- When possible, provide clients with stays that are long enough so their symptoms can stabilize and be near baseline when they are discharged.
- Upon release, work with the client to develop a solid aftercare plan that includes service options, appointments, crisis line information, etc.
Lastly, discharging from Pathway to Care is a cause to celebrate! We will continue to work collaboratively when a client has been on the Pathway to Care. The discharge is staffed by the case manager, clinical supervisor, and program manager. Together, they help put more “eyes” on the case and ensure the client’s needs have been met.
- Nancy Elliot, MS, LPCS; Licensed Professional Counselor/Supervisor; Adult Mental Health Program Administrator; The Betty Hardwick Center
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