Bronson Healthcare system serves patients and families throughout southwest Michigan and northern Indiana by offering a full range of services from primary care to advanced critical care. In 2015, Bronson created a behavioral health department and, in 2016, was awarded a $160,000 grant from Priority Health to develop integrated behavioral health (IBH) teams and to implement Zero Suicide in all settings, starting with primary care. After engaging with senior leadership and staff to improve suicide care in their organization, Bronson observed the following key outcomes from 2016 to 2019.
- Patient Health Questionnaire-9 (PHQ-9) screening increased from 40% to 65% during the grant period, and many of the clinics are now completing screening with over 80% of patients at least once per year.
- The IBH workforce increased from 6 to 25 medical social workers (MSWs) in 26 clinics; they conduct suicide risk assessments and safety planning for patients at risk of suicide.
- Referrals to emergency departments (EDs) for the evaluation of suicidal ideation have decreased as a result of a robust integrated behavioral health program in primary care.
- Recent data (March–June 2019) from outpatient clinic sites found the following:
- 20% of PHQ-9 screens in adults and 25% of PHQ-9 screens in teens were positive for depression.
- 7% of adult screens completed and 15% of teen screens completed revealed suicidal ideation.
About Bronson Healthcare System
Bronson Healthcare system, located in southwest Michigan, serves patients and families throughout southwest Michigan and northern Indiana by offering a full range of services, from primary care to advanced critical care. Through its four hospitals, Bronson provides medical and surgical care; four EDs (two rural and two urban sites); a children’s hospital in the Kalamazoo area; outpatient primary care practices (26 total, including internal medicine, family medicine, pediatrics, and OB-GYN); a 35-bed adult inpatient psychiatric hospital; and a 10-bed geropsychiatric inpatient hospital.
Broad Implementation Overview
In 2015, as part of meeting the Medicare/Medicaid Meaningful Use Requirements, primary care providers (PCPs) began screening adults and children (12 years and older) for depression using the PHQ-2 and PHQ-9. Nationally, at this time, most PCPs were not receiving formal training in the use of these tools. Suicide prevention-specific education has not historically been a part of medical training, and oftentimes PCPs relied upon EDs to evaluate patients who screened positive for suicide risk. After identifying the need for improved behavioral health care services and suicide prevention, Bronson opened a Behavioral Health Department. In 2016, Bronson was awarded a $160,000 grant from Priority Health Regional Development. With this funding, Bronson brought a team of experts from the Zero Suicide Institute to Kalamazoo to help guide Zero Suicide implementation.
Initial Zero Suicide implementation activities included presentations for the Bronson executive team, ED leadership; the social work IBH team; Western Michigan University Homer Stryker School of Medicine medical students, residents, and faculty; and key stakeholders in the region, including community mental health agencies, regional psychiatric inpatient hospital leadership, Gryphon Place crisis center, area philanthropists, leadership from the Family Health Center (a Federally Qualified Health Center), Kalamazoo Public School superintendent, and community members.
Leadership adopted suicide prevention as an important goal for Bronson, and we now support strategic plans to continuously assess data, implement process improvements, and promote staff education across the system. Our Zero Suicide implementation team regularly informs leadership teams about progress made during the Zero Suicide rollout.
“Following Zero Suicide implementation, PCPs and MSWs have an increased confidence that most patients with suicidal ideation can be assessed and cared for in the primary care setting.”
As Bronson began building its Zero Suicide initiative, it simultaneously placed six medical social workers (MSWs) in 12 of the primary care practices to provide on-site behavioral health services, known as integrated behavioral health (IBH). IBH allows patients to receive mental health care in the PCP office. Implementing IBH has been a tremendous success and has been key to our Zero Suicide initiatives. We are now closely tracking PHQ data. In one quarter, 24,000 screens were administered, and approximately 20% of adults and 25% of teens had positive depression screens. Of those screens, 7% of adult screens and 15% of teen screens revealed suicidal ideation. As a result of this data, the IBH team has grown to 25 MSWs in both primary care and some specialty practices to meet the needs of our patient population.
Training and Partnerships
One of Bronson’s Zero Suicide implementation actions was to complete the Zero Suicide Workforce Survey. We planned to use the survey results to strategically build a comprehensive training plan and then to repeat the survey after some time to assess the increase in staff knowledge and confidence. Our 2018 Zero Suicide Workforce Survey data from primary care clinics and EDs indicated that while staff clearly saw suicide prevention as an integral part of their roles, 50% of staff surveyed still needed more training. Moving forward, comprehensive suicide prevention education is a priority for the system, and our suicide prevention training plan will include online learning modules on general suicide prevention for all staff and specialized modules for clinical processes, such as administering the Columbia-Suicide Severity Rating Scale (C-SSRS) in the ED.
Additionally, to build community capacity for suicide-specific treatment options, two training opportunities were offered for Collaborative Assessment and Management of Suicidality (CAMS). One of the trainings was held for only the Bronson MSW team, and then a second training was held for both the MSW team and three community mental health agencies. All agencies shared the cost of the training, and a total of 60 therapists completed the CAMS training. A continuing education (CEU) workshop was created for the Stanley and Brown Safety Planning Intervention, and it has been offered to social workers who cover both primary care sites and EDs. A training for a regional community mental health center was held in August 2019 to train 30 mental health staff in safety planning to help increase the capacity for suicide-specific care in the region. Bronson continues to keep training as a priority as Zero Suicide implementation continues.
“Since having access to an MSW who knows how to care for suicidal patients, I have not needed to send a single patient to the ED for evaluation in the past two years.”
Bronson holds community partner events, such as the Safety Planning Intervention Workshop, in three counties to share best practices. Bronson also participates in the Kalamazoo County Suicide Prevention Action Network (SPAN) and the Suicide Death Review Team Participation in both Kalamazoo County SPAN and the Suicide Death Review Team ensures that Bronson’s suicide prevention efforts are part of a larger effort to reduce suicide, and it helps in the review of suicide deaths in individuals who receive care in Bronson hospitals, EDs, and outpatient practices. Bronson has also partnered with Gryphon Place, a local crisis call center, to provide follow-up calls to ED patients and inpatients with suicidal ideation from medical units who had been assessed and cleared for discharge to go home. Patients who consent to follow-up calls are contacted within 24–72 hours following discharge.
Collaborating with other partners in the community and surrounding regions is invaluable. Health care providers and systems alone cannot provide the comprehensive care and safety net that those at risk of suicide need. Additionally, reaching out to the international suicide prevention community is extraordinarily helpful. The Zero Suicide listserv provides an accessible platform for asking questions, sharing ideas and experiences in a variety of settings, and highlighting resources.
Initially, many health care practices were using the PHQ-2. However, as part of its Zero Suicide initiative, Bronson adopted the universal use of the PHQ-9 (with a modified version for teens) for annual physical exam visits. We have just begun data collection to assess compliance with this safety measure. Processes have been implemented to complete the C-SSRS with patients who have any suicidal ideation. Following risk assessment, safety planning is completed for patients determined to be at moderate to high risk. We are also revamping suicide prevention practices in our ED and standardizing a system wide suicide prevention policy to meet Joint Commission National Patient Safety Guidelines, which includes a protocol for administering the C-SSRS.
As a result of increased access to on-site MSWs trained in the assessment and management of suicidal ideation, patients are much less likely to be referred to the ED for the evaluation of suicidal risk. As one physician noted, “Since having access to an MSW who knows how to care for suicidal patients, I have not needed to send a single patient to the ED for evaluation in the past two years.” What was once (as described by the Zero Suicide website) the “heroic efforts of individual clinicians” has become a collective team effort. Following Zero Suicide implementation, PCPs and MSWs have increased confidence that most patients with suicidal ideation can be assessed and cared for in the primary care setting. Once safety planning and lethal means counseling are completed in the office, most patients are now sent home and provided with coordinated follow-up care, which may include a referral to therapists in the community, phone calls, caring cards, and/or a follow-up PCP/MSW appointment. The improvements in suicide risk identification processes and access to on-site MSWs has contributed to increases in screening rates.
- Data from 2016 to 2017 showed that PHQ-9 screening rates increased from 40% to 65%, and many of the clinics are now completing screening for over 80% of patients at least once per year.
- For the period of April 1 to June 30, 2019, over 24,000 PHQ screens were completed in 26 clinics, and of those, 1,400 (7%) adult screens and 237 (15%) teen screens indicated suicidal ideation.
Running data reports can be challenging, but they are essential. We found that for the purpose of tracking data, strong electronic health record (EHR) builds are needed. Generally, these must be created by individual institutions. While this allows institutions the flexibility to tailor processes, IT departments require time and resources to develop the platform. Many EHR providers offer libraries that share projects from other institutions, which can be helpful.
As our Zero Suicide initiative continues, we are looking to improve data collection to track C-SSRS risk assessment completion for any patient with suicidal ideation and completion of safety planning for patients with high suicide risk. By implementing an EHR function that improves linkages with community agencies, we hope to assess the closed-loop follow-up of at-risk patients in collaboration with our community behavioral health partners to determine patient outcomes. We plan to incorporate a C-SSRS EHR pathway for universal screening in the ED and inpatient medical units. Additionally, to improve internal processes, we will utilize data from our county’s Suicide Death Review Team to conduct root cause analysis of suicide cases in which individuals received care in the Bronson system.
With respect to training, we aim to create a formalized, comprehensive education plan for staff tailored to their responsibilities and role. To help inform this, we plan to administer the Zero Suicide Workforce Survey in September 2019 and then re-administer the survey to primary care, ED, and inpatient units in 2021. We would also like to increase utilization of follow-up calls for patients with suicidal ideation who are later discharged from inpatient medical units, outpatient clinics, and EDs by developing standardized processes practices for staff and by enhancing EHR workflow. Lastly, Bronson will continue to participate in local, state, and national initiatives that promote suicide prevention.
- J. Lia Gaggino, MD, System Medical Director Behavioral Health, Bronson Healthcare
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