Centura Health participated in a Zero Suicide Academy® in 2015, piloted the Zero Suicide initiative in 2018, and launched implementation across all its Colorado hospitals in 2019. Currently in year four of implementation, Centura has used data on key process measures to continually refine its efforts.
Key Outcomes:
- Established a process for linking coroner data on suicide deaths with Centura’s electronic health records to identify trends and gaps in care. Six months into the process, Centura made changes to its level-of-care assessments based on data analysis results.
- Performed a suicide risk screening audit and found that using the recent history (past-30-day) version of the Columbia Suicide Severity Rating Scale (C-SSRS) more effectively identified individuals at risk for suicide at Centura than the version assessing lifetime history.
- Conducted monthly audits of the hospital care transitions initiative and clinician referrals to the program starting in 2021. Based on these audits, Centura implemented quality improvement measures that resulted in a 33% increase in the number of individuals appropriately referred to the program, and a 49% increase in the program’s approval rating from the individuals served, over a six-month period.
- Developed a Caring Contacts follow-up program for individuals with suicidal thoughts or behaviors who were discharged from the emergency department. In 2022, Centura also began tracking health inequities among individuals served by this program. This resulted in a collaboration with Colorado’s U.S. Department of Veterans Affairs (VA) office to help provide needed resources to veterans.
Centura Health
The largest hospital provider in Colorado, Centura Health is a nonprofit organization with 17 hospitals and 250 provider locations across Colorado and western Kansas. Centura has robust behavioral health services, including intensive outpatient programs for mental health, substance use, and dialectical behavior therapy; adult and geriatric inpatient psychiatric units; a level-of-care assessment center; and a crisis assessment team.
Zero Suicide Implementation Journey
After participating in a Zero Suicide Academy in 2015, Centura Health began laying the foundation for implementing Zero Suicide. In 2018, Centura piloted the initiative at two of its hospitals. In 2019, Centura hired a full-time Zero Suicide coordinator and began incorporating the framework into all its Colorado hospitals. In 2020, the Colorado Healthcare Affordability and Sustainability Enterprise (CHASE) established Hospital Quality Incentive Payments (HQIP) to improve the quality of care at hospitals across the state. At that time, Zero Suicide was adopted as an HQIP measure, which helped to propel implementation efforts.
Leadership and Growth
Centura’s Zero Suicide implementation has expanded greatly over the past four years. For example, the number of hospitals participating in the Zero Suicide Organizational Self-Study increased from 1 Centura hospital in Colorado to all 16 in that state and 2 in Kansas. This expansion required strong implementation teams with multiple levels of leadership representation. Centura has a primary implementation team for the whole system as well as facility-based and associate-focused teams.
One of the most important factors for maintaining and growing Centura’s Zero Suicide implementation is executive-level sponsorship and support from the CEO. This executive sponsorship has enabled critical collaboration and coordination among the implementation teams and senior leadership across Centura facilities.
Leadership support has also facilitated organization-wide, high-visibility communications on suicide prevention and related progress, such as the results of the Zero Suicide Workforce Survey. Facility-based and organizational newsletters have helped spread the vital message that suicide prevention is a core priority. These communications have been instrumental in recruiting ambassadors (e.g., Zero Suicide implementation champions—both front-line and senior-level staff) and identifying staff with experience in suicide care who want to be involved in Zero Suicide.
Training Initiatives
In addition to participating in a Zero Suicide Academy, Centura focuses on ensuring all staff have the knowledge, skills, and confidence to serve in their expected roles in suicide prevention. Staff are annually assessed for training needs using the Zero Suicide Workforce Survey, which is now distributed to all Centura staff. Survey results have informed training opportunities as well as discussions with staff across facilities to better understand specific staff training needs. This includes continuing to focus on appropriately serving populations with unique needs who may be at high risk (e.g., individuals receiving transplant services, individuals who identify as LGBTQIA+, and veterans) in our trainings. Trainings are offered at least quarterly. Centura’s current training efforts include:
- LivingWorks Start and Question, Persuade, Refer (QPR) trainings to recognize and respond to those at risk
- LivingWorks ASIST intervention training
- C-SSRS training
- Counseling on Access to Lethal Means (CALM) online course
- Staff-focused trainings to address compassion fatigue, self-care, and burnout
Screening and Safety Assessment
Establishing clear guidance for suicide risk screening, assessment, safety planning, and ongoing care is an organizational priority. A key accomplishment in this area is standardized screening using the C-SSRS, which has expanded from individuals with a behavioral health concern (selective screening) to all individuals served (universal screening). Importantly, Centura routinely audits C-SSRS screens, which guided the decision to shift from using the lifetime version to using the past-30-day version of the C-SSRS. In addition, previously only individuals who screened moderate and high risk for suicide received an assessment and further intervention. Centura now provides interventions such as safety planning, education, and suicide prevention resources to all individuals who have screened low, moderate, or high risk for suicide, as well as suicide risk assessment when indicated.
Individuals being discharged after a crisis assessment and those participating in outpatient services work with a clinician to develop a safety plan using the Stanley-Brown Safety Planning Intervention. Additionally, all crisis assessment teams are trained in CALM and employ these skills as part of safety planning. Centura has established a level-of-care assessment center, which focuses on suicide risk assessment, ensuring warm hand-offs, and planning for appropriate ongoing care. This center also serves as an intake for individuals who are appropriate for our intensive outpatient programs.
Strengthening Care Transitions
Centura is part of the Rocky Mountain Crisis Partners (RMCP) Hospital Follow-Up Program in Colorado. This program was developed to ensure that individuals who were evaluated for suicidal thoughts or behaviors in an emergency department and discharged receive phone follow-up. During this time of heightened suicide risk, staff from RMCP call those who consented to follow-up, within 24 hours of hospital discharge. The clinicians who conduct safety assessments at the hospital enroll eligible individuals into this program prior to discharge to ensure a warm hand-off. Trained specialists provide follow-up for those with minimal safety risk but need additional support and encouragement, and master’s level clinicians are involved when there are immediate safety concerns. To monitor and increase the use of this program, Centura has:
- Tracked the number of RMCP referrals
- Incentivized clinicians to refer to RMCP by offering opportunities to earn gift cards
- Begun tracking numbers of RMCP warm hand-offs and auditing clinician referral percentages
Centura also implements a Caring Contacts program that includes peer support specialists with lived experience. All individuals who are discharged after being seen in the emergency department for suicidal thoughts or behaviors are automatically enrolled in this program and receive a call from a Centura peer specialist 48 to 72 hours after discharge. The purpose of the program is to ensure individuals at risk for suicide are connected with resources, problem solve around barriers to treatment, reinforce safety plans, and provide additional support post discharge. Peer support specialists review the individual’s safety assessment, safety plan, and the specific resources offered prior to placing the outreach call. This ensures that peer support specialists have a full understanding of why the individual presented to the emergency department, their safety plan, and are able to address resource needs.
Key Process Outcomes
1. Analysis of Coroner Data
In 2021, Centura began collecting and analyzing suicide data from the Denver County coroner and cross-referencing it with electronic health records to identify individuals served by Centura who died by suicide. These data were used to identify trends and gaps in care for individuals engaged in treatment (seen in the past year), as well as those not engaged in treatment (not seen in the past year). Based on an analysis of six months of data, Centura found an association between lack of record review during level-of-care assessments and individuals dying by suicide. Acting on this finding, Centura guided clinicians who conduct level-of-care assessments to review records from previous visits and identify any documented high-risk suicidal behaviors that should be incorporated in the comprehensive assessment.
2. C-SSRS Screening Audit
Based on an audit of its C-SSRS screening data, Centura determined that changing from the lifetime version to the past-30-day version of the C-SSRS would help increase the accuracy of risk identification and support clinicians in planning for the appropriate level of care for individuals who are screened across different settings.
3. RMCP Hospital Follow-Up Program Audit
Centura conducts monthly audits of its RMCP Hospital Follow-Up Program to:
- Monitor program utilization by Centura clinicians
- Track whether all individuals who are eligible for the program are referred through a warm hand-off
- Determine if individuals enrolled in the program receive calls within 24 hours after discharge
- Assess satisfaction among individuals served by the program
“I found the people at RMCP very helpful. I was scared when I left the hospital. They followed up with me each week for over a month until I felt safe on my own.” – RMCP program member
To assess program utilization, clinician referral data were analyzed and given to team supervisors for follow-up. In most cases, clinicians who were not making referrals did not understand the follow-up program eligibility criteria. Once this issue was identified and additional training provided in 2021, the percentage of clinicians making appropriate referrals increased dramatically (see Table 1).
Table 1. Percentage of clinicians making referrals to RMCP
|
January 2021 |
June 2021 |
January 2022 |
June 2022 |
|
|---|---|---|---|---|
|
Percentage of Clinicians Referring to RMCP |
3% |
85% |
90% |
95% |
In its assessment of appropriate referrals, Centura found the number of individuals discharged from the emergency department who were appropriately referred to RMCP follow-up services increased by 33% over a six-month period. This increase coincides with the January to June 2021 increase in the percentage of clinicians referring to RMCP shown in Table 1.
To improve participant satisfaction, Centura used feedback from individuals served by the program to inform an improvement in RMCP’s procedures. These satisfaction data led to referral procedure changes that resulted in a 49% increase in approval rating in the six-month period from initial survey to full implementation of RMCP’s revised procedures.
4. Outreach and Caring Contacts Audits
To help advance its commitment to health equity, Centura tracks the resources it provides to individuals who identify as LGBTQIA+, veterans, people of color, people with disabilities, and Indigenous. This commitment aims to support engagement in follow-up treatment for suicidal thoughts or behaviors after emergency department discharge. One audit found that veterans had difficulty understanding their VA benefits and accessing appropriate VA resources. As a result, Centura has entered into a 14-month collaboration with VA to better understand how to connect veterans with VA services. This ongoing partnership provides VA with an opportunity to learn about mental health care barriers for veterans served by Centura, and enables Centura to better support individuals referred to the VA network.
Next Steps
- Further investigate trends in suicide death data and adjust Centura’s policies, procedures, and clinical workflows to enhance suicide prevention efforts
- Establish a shared data agreement with the Colorado Department of Public Health and Environment to obtain suicide death data from coroners in every county where Centura facilities are located
- Continue to promote the RMCP Hospital Follow-Up Program with Centura clinicians to ensure individuals discharged from the emergency department receive the highest standard of care
- Extend the peer specialist role to support individuals discharging from intensive outpatient programs
- Build a suicide care pathway to share across primary care through inpatient behavioral health
- Continue to use the Zero Suicide Workforce Survey to understand staff perceptions and needs within the Zero Suicide framework
- Begin post-grant sustainability planning
Authorship Details
Christina Dolan, Zero Suicide Coordinator, Centura Health
Heidi Bode, Behavioral Health Team Manager, Centura Health
For more information, contact Heidi at heidibode@centura.org