Organization Profile
Lakeshore Community Health Care (LCHC) is a federally qualified health center and patient-centered medical home serving Wisconsin communities with primary care, behavioral health, dental, chiropractic, and pharmacy services. LCHC’s mission is to improve access to healthcare for all and one of the strategies used to accomplish this is the practice of behavioral health integration via the Primary Care Behavioral Health model. LCHC is a leading provider of school-based behavioral health, delivering services in more than 70 schools across our footprint.
In 2024, LCHC provided more than 52,000 visits to 14,000 patients, most of whom are low-income: 86% fall below 200% of the federal poverty level, and over 60% are Medicaid-enrolled.
Implementation of Zero Suicide
In 2023, LCHC recommitted to behavioral health integration, increasing fidelity to our PCBH model, and enhancing suicide prevention capacity across its clinics. Efforts included:
- Workforce-focused communication and socialization of whole-person health, including behavioral health and suicide-specific messaging.
- Visible patient-facing messaging and promotion of the 988-crisis line and suicide prevention and awareness.
- Workforce training: organization-wide QPR (Question, Persuade, Refer) training — more than 75% of staff trained, with QPR incorporated into onboarding and biannual refreshers.
- Behavioral health-specific training: delivered Assessing and Managing Suicide Risk for Outpatient (AMSR-OP) to 97% of behavioral health staff and 75% of nursing staff. Behavioral health staff are also trained in Safety Planning Intervention, CALM and the C-SSRS.
- Implementation of suicide screening in all dental clinics.
EHR optimizations to facilitate adherence and reporting (fidelity and clinical disposition).
Suicide Screening Efforts
Initial screening efforts were focused on our dental clinics. The decision to start work in dental was intentional for a number of reasons, including past efforts to integrate behavioral health through broad mental health screening. As an integrated health system, LCHC recognized the critical intersections between oral health, physical health and behavioral health. By fostering this communication and awareness, they laid the groundwork to expand integration into dental beyond suicide-specific screening (i.e., social drivers of health and substance use). It also served as a precedent to demonstrate the feasibility of suicide screening outside of behavioral health, across clinical disciplines and populations.
Screening initially began with “annual hygiene” visits for all patients aged 11 and older. Within two months of launch, dental hygienists achieved 91% screening adherence, and there was interest in expanding screening to include all “new patient” visits. Adherence remained high at 87% following the screening expansion.
Response Protocol
When a patient screens positive, BH case managers (BHCMs) or BH Consultants (BHCs) provide response in person or via telehealth. The protocol stratifies the response based on triage risk, with high-risk patients receiving same-day warm hand-offs and low-risk receiving follow-up within 72 hours. However, our goal is that all positive screens are seen same-day, in-person whenever possible. BHCMs are engaged via EHR-based secure chat and they complete secondary risk assessment, using the C-SSRS Lifetime Clinical Scale or SAFE-T. They also deliver brief interventions, create safety plans using the Stanley Brown model, counsel on lethal means safety, and connect patients to further care.
Key Outcomes
- Approximately 7% of dental patients screened positive for suicide risk.
- Risk stratification showed: 1.6% low risk, 5% moderate risk, and 0.7% high risk.
- Most patients who screen positive (high and moderate risk) are already engaged in support services (therapy, psychiatry).
- In 3 years of dental screening, LCHC have never had to engage local crisis services, call 911, or transfer a patient to a higher level of care.
- Developing scripting for the dental team to talk to kids and families about screening has been key.
- Telehealth response to patients has been feasible and appropriate.
- Implementing suicide screening has increased the identification of dental patients in need of other psychosocial supports and resources, enhancing connection to address housing, food insecurity, unmet health needs, and other mental health concerns.
Next Steps
LCHC intends to expand consistency of suicide screening across our health centers and service lines. Presently, suicide screening is delivered when indicated in primary and behavioral health care, and routinely at intake and treatment plan review for outpatient BH services. LCHC will continue providing workforce-wide and behavioral health specific training (e.g., making AMSR available at least once a year to address new and turnover staff). They also intend to better integrate AMSR-focused formulation into our documentation templates within the EHR.