Outcome Story

The Chickasaw Nation Departments of Health and Family Services began Zero Suicide implementation in September 2016, first starting in the emergency department (ED) and soon after expanding to all clinical settings (outpatient clinic visits, dental visits, ED visits, acute and intensive care unit admissions). The Department saw a number of key outcomes.

Key Outcomes:

• Before Zero Suicide implementation, patients received similar care regardless of their level of suicide risk and as a result, on average, 120-150 suicidal patients were admitted for inpatient treatment per year.
• Between December 2016 and June 2018, implementation of standardized screening, suicide risk assessment, collaborative safety planning, and follow-up care practices has led to, on average, 200 diversions from admission to inpatient treatment per year.
• Cost savings estimates indicate that each inpatient admission costs approximately $1,100, and that diverting patients from inpatient care has saved over $200,000 per year. 

Zero Suicide Implementation

The Chickasaw Nation is bold and assertive in providing the best possible health care for Chickasaw citizens and other Native Americans. In 1994, the Chickasaw Nation became one of the first Tribal Nations in the United States to manage our own health care system. Now, the Chickasaw Nation operates a hospital connected to a variety of outpatient clinics, three rural satellite clinics, eight pharmacies, a diabetes care center, an ambulance service, four nutrition services centers, eight WIC offices, and five wellness centers throughout south-central Oklahoma. In the five and a half years since its opening, the Chickasaw Nation Medical Center has built an international reputation for compassionate, quality health care. Today, it stands as a paradigm of tribal health care that serves Chickasaws and other Native Americans from across Oklahoma and even from other states.

According to the American Foundation for Suicide Prevention, as of 2017, suicide is the second leading cause of death for ages 10-34 and the eighth leading cause of death overall in Oklahoma. More than twice as many people die by suicide in Oklahoma annually than by homicide. Additionally, with 39 tribes located in Oklahoma, it is worth noting that the suicide rate in American Indian/Alaska Native populations (AI/AN) has increased since 2003 and in 2015 it was over 3.5 higher than rates for racial/ethnic groups with the lowest rates.1  It is apparent that being American Indian/Alaskan Native living in Oklahoma carries statistically high-risk factors for suicide even before further risk factors are considered like trauma history, addiction experiences, socioeconomic status, and geographic location.

In 2015, a unique opportunity was provided to the Chickasaw Nation when we were accepted as one of 11 health systems, and the only Oklahoma tribal health system, to be mentored for three years for Zero Suicide implementation by the Oklahoma Department of Mental Health & Substance Abuse Services (ODMHSAS), who had been funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) for these partnerships. At that time, there with a specific focus on implementing Zero Suicide at the Chickasaw Nation Medical Center Emergency Department (ED).

The Chickasaw Nation Departments of Health and Family Services began an integrated effort of planning for implementation of Zero Suicide in 2015 by meeting with the key stakeholders to determine the best way to implement this program. At that time, we also reviewed our current practices around care management for suicidal patients and identified multiple gaps in our processes, including lack of a screening process for high-risk patients in the ED (averages 4,500 patient visits a month). One critical support for this aspirational endeavor was The Joint Commission’s (TJC) release of Sentinel Event Alert 56, which focuses on detecting and treating suicide ideation in all health care settings. As a TJC accredited system, prioritizing suicide prevention in Sentinel Event Alert 56 provided a key opportunity to educate many of our staff on Zero Suicide. The initial “go live” of Zero Suicide began in September 2016, in the emergency department and soon after in the rest of the health system to better identify, screen, and assess persons at risk for suicide and to provide appropriate transitional care and treatment to those we identified. It was quickly apparent in our gap assessment that our system would best be served to improve the risk identification processes in multiple areas of our health system.

The goal from the outset has been to have uniform screening, assessment, and treatment of persons at risk for suicide, no matter what access point of care is engaged within our services. With the uniform processes, we hoped to identify risk early, streamline care, divert patients from unnecessary inpatient treatment stays and provide thorough follow-up to keep patients from “falling through the cracks.” To accomplish this, The Chickasaw Nation has worked diligently to implement a workflow that includes screening, assessment, safety planning, and follow-up. 

The goal from the outset has been to have uniform screening, assessment and treatment of persons at risk for suicide, no matter what access point of care is engaged within our services.

Our Suicide Care Workflow

Screening:

This workflow starts with all patients receiving a Patient Health Questionnaire (PHQ-2) depression screening at their visit, which includes inpatient and outpatient services, dental and physical therapy. A patient with a positive depression screening then visits with a member of our integrated behavioral health team for further screening utilizing the PHQ-9 for depression and suicide risk. The screening score and answer to question number nine on this screening guide the clinician on use of an additional suicide screening called the C-SSRS (Columbia Suicide Severity Rating Scale).  All patients who present to the ED are dually screened with the PHQ-2 and C-SSRS for depression and suicide risk, respectively. Our mental health staff is present during normal business hours to further connect with those at high risk. After-hours, ED medical staff and an on call crisis contractor manages these steps for those indicated for intervention based on screening scores.

Assessment:

If the patient is identified as at risk for suicide, the therapist further interviews the patient to assess level of risk (low, moderate, high) based on clinical judgment, which assists in making the decision for their care and documents risk level in the electronic health record share with the medical team.  Decisions about level of risk are broadly summarized below:

• If the patient is at low risk for suicide, the therapist works with the patient to create a collaborative safety plan as part of our identified process. 
• If a patient is at moderate risk for suicide, the therapist often uses clinical judgment of patient’s life context and screening scores to assess whether the patient can be safe utilizing a safety plan and their support system, or would be best treated in an inpatient facility.
• For high-risk patients, the therapist usually plans with the family for the patient to be admitted to inpatient treatment, but again if the therapist’s judgment determines the patient has a strong support system, completes a safety plan and shows commitment to follow-up, it could be decided the patient leaves with their family. Standardization of who to send to inpatient treatment is often difficult to define at the outset because the nature of each patient’s risk varies. 

Safety Planning:

We used the Safety Planning Intervention developed by Stanley and Brown (2012). The safety plan allows the patient to identify positive coping strategies, members of their support system, and important contact information for those whom the patient can call on if needed.  

Follow-Up:

Before the patient leaves the facility the therapist creates a follow-up appointment with the patient and plans phone follow within 72 hours up that includes risk screenings for patients we have not seen in the clinic for an appointment. We utilize administrative staff to identify no-shows and track those at the highest risk so they can be contacted. Therapists also encourage patients to complete our Heartline contact consent form. Heartline is an outside hotline that assists with patient follow-up.  It is of great importance to make these follow up appointments for the patient before they leave so they experience little to no gap in services, including medication refills.

Prior to our Zero Suicide implementation patients who received inpatient care did not receive standardized follow-up contact post-discharge, and at times our care processes would end when the patient left our facility. Now, for patients who are referred to inpatient care we have created a unique discharge form that includes their follow up information and upcoming appointments.

Implementation Outcomes

In our first year (December 2016-September 2017 FY17), we provided over 125,000 depression screenings at patient visits with approximately 17,000 C-SSRS suicide screenings necessitated by depression screening response. This suicide-specific screen identified approximately 350 patients at moderate to severe risk for suicide. Among those 350 patients at moderate to severe risk we collaboratively completed a safety plan with 245 patients and 172 consented to follow up by the Heartline service.  A majority of our moderate to high risk patients have completed a safety plan, and approximately 44 have been documented as denying completion of a safety plan. 

In the first nine months of our second year (October 2017-June 2018 FY18), we have provided over 151,000 depression screenings, 11,000 C-SSRS suicide screenings and identified 275 at moderate or high risk. The data included in the table below aggregates all patients from all clinical settings (outpatient clinic visits, dental visits, ED visits, acute, and intensive care unit admissions). 

“The more we have listened to our patients and reviewed relevant research, it is evident that inpatient treatment is not always a viable option to ensure improvement and success. It additionally adds a critical risk window once they discharge that we can avoid through diversion.”

	December 2016-September 2017	October 2017-June 2018
Depression Screenings (PHQ-2 and/or PHQ-9)	>125,000	>151,000
Suicide Risk-Screenings (C-SSRS)	>17,000	>11,000
Moderate to High Risk	350	275
Safety Plan Completion (Stanley & Brown) among those screened with C-SSRS	245	222
Heartline Referrals	172	123
Made Follow-Up Appointment	144	155

Diverting Patients from Inpatient Treatment:

Diverting Patients from Inpatient Treatment:

With the implementation of a workflow around suicide care, and more specifically the implementation of a standardized safety planning process, we have been able to instill confidence throughout our system in managing at risk patients. This has allowed our team to manage at risk patients rather than defaulting to external inpatient treatment.

• This has led to, on average, over 200 diversions from admission to inpatient treatment per year because we are able to now consider a return home with safety measures and follow-up planning as our first choice of intervention.

• Inpatient treatment is only considered for those who are at severe risk, lack a strong enough support system to confidently ensure their safety and/or those who refuse to complete a safety plan.

The more we have listened to our patients and reviewed relevant research, it is evident that inpatient treatment is not always a viable option to ensure improvement and success. It additionally adds a critical risk window once they discharge that we can avoid through diversion.  Facilities in our area are often over 60 miles away causing immense use of resources for the transportation to and from the facility. Cost savings in transportation has been an immense blessing to our tribal police and patient families.

• Before standardized screening for depression and suicide, patients received similar care regardless of their level of risk, and as a result, on average, 120-150 suicidal patients were admitted for inpatient treatment as the primary option.
• Current data suggests that with the implementation of better detection practices and screening, though more patients are identified for low, moderate, or high risk each year, there are fewer patient admissions to inpatient care due to early identification and intervention, safety planning and standardized follow-up practices.

This means our Native American patients stay with their families during their crisis, utilize their community and cultural supports and have a higher likelihood of checking back in with us sooner than if they entered inpatient treatment and saw us upon discharge, if they kept appointments. 

Cost Savings:

With momentum from the standardization of our processes and tracking numbers of diversions, we wanted to look at how much it was actually costing our system to manage someone in the ED, identify risk and send them to inpatient treatment. As many of our patients who present in the ED are non-resourced, our cost analysis looked at nine random cases for patients without third-party funding resource. For this sample of cases, the average cost of a crisis patient receiving care in the ED and then being transported to an inpatient facility at least 60 miles away was $1,100. Decreasing the number of patients we would have referred for inpatient treatment, and instead diverting them from inpatient care, saves our system over $200,000 per year because patients leave with their families and with a plan for safety and follow-up instead of leaving our care system. The hundreds of thousands of dollars saved throughout the duration of this work could fund more crisis clinicians to provide the screening, triage and follow-up services that support inpatient treatment diversions, which could further propagate the currently observed cost savings. 

Future Plans:

• The impact of universal screening in the ED will be a key point to study in the future. If we are screening everyone at every entry point in our system, it may reduce the number of patients presenting in the ED in crisis.
• We have been tracking whether patients return to the ED for another psychiatric crisis within 30 days of discharge from inpatient care, and only one patient returned. In FY19, we will be tracking return ED visits among patients discharged from inpatient care for a full year, in addition to 30 days post-discharge.
• Identify ways of capturing more accurate attempt data and suicide death statistics in our communities.
• While we began with the Zero Suicide elements Lead, Train and Identify, we have also worked more in our third year to address the Engage, Transition, and Improve elements. In our next year we will be moving more intentionally to develop specific treatment approaches that will be adopted by our clinicians as part of the quality follow up care we want to provide. 

Reflection

What we would have done differently:

• Start the identification process with the PHQ-3 instead of the PHQ-2.
• Establish plans for ongoing staff trainings beyond the first year of Zero Suicide implementation.
• Create a system-wide policy to adopt Zero Suicide earlier in implementation to assist with full system buy-in and ensure compliance.
• Advocate earlier for care coordinators and other staff who can help manage patients in transition.
• Plan for leadership and staff turnover and ensure all new hires are trained to understand Zero Suicide implementation.
• Coordinate with state contracted crisis coverage service that sees our patients on nights and weekends earlier in implementation planning to streamline patient engagement processes.
• Establish plans for tracking suicide attempt and death data. 

Lessons learned:

• Embed implementation steps in the electronic health record (EHR) whenever possible!
• Modify current documentation templates to incorporate your new screening and assessment practices.
• Conduct chart reviews periodically to ensure documentation is accurate.
• Personalized follow-up with patients makes a huge difference (i.e. phone call or handwritten caring contact note).
• Nursing plays a huge role in Zero Suicide.
• Start collecting data from the beginning (use the Zero Suicide Data Elements Worksheet as a guide).
• Review data often and share it widely.
• Hire or select Zero Suicide implementation team members intentionally.
• Recruit as many champions as you can. 

Authorship Information

• Dr. Shannon Dial, LMFT, Executive Officer, Integrated Services Division
• Dr. Amber Anderson, LMFT, Director, Medical Family Therapy
• Barbara Underwood, MS, LCSW, Director, Prevention Services
• Deanna Carpitche, MS, Prevention Specialist
• Troy Scalise, Clinical Informatics Manager

For more information contact Dr. Shannon Dial at Shannon.Dial@chickasaw.net.

• 1.Leavitt, R. A., Ertl, A., Sheats, K., Petrosky, E., Ivey-Stephenson, A., & Fowler, K. A. (2018). Suicides Among American Indian/Alaska Natives—National Violent Death Reporting System, 18 States, 2003–2014. Morbidity and Mortality Weekly Report, 67(8), 237-242. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6708-H.pdf