The Mental Health Center of Greater Manchester (MHCGM) in New Hampshire is a private nonprofit system and Community Mental Health Center. With its mission of transforming the lives of individuals, families, and the community, it has provided an evidence-based, comprehensive system of behavioral health care to the greater Manchester community for over 60 years.
During its first year of implementing the Zero Suicide approach, MHCGM accomplished the following:
- Decreased suicide deaths by 44%
- Trained 80% of staff in suicide prevention
- Enhanced the provision of evidence-based practice (EBP) by training clinical staff in Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) and developing a two-day Dialectical Behavior Therapy (DBT) overview for all clinical staff not providing full DBT
- Assessed suicide risk in 100% of active clients
Organizational Overview
Designated as a Community Mental Health Center by the NH Bureau of Mental Health Services, The Mental Health Center of Greater Manchester (MHCGM) provides a broad range of services to 11,000 individuals annually, including business leaders and their employees, educators, veterans, seniors, and thousands of children. The largest provider of outpatient behavioral health services in New Hampshire, MHCGM has 450 employees operating over 30 programs and is affiliated with the Geisel School of Medicine at Dartmouth. MHCGM is located in downtown Manchester, which constitutes New Hampshire’s urban center, and is a federal refugee resettlement zone. The population of Manchester is 77% White, 10.5% Hispanic, 5.5 % Asian, 4.2% Black/African American, and 2.3% two or more races.
Within our continuum of projects, programs, and initiatives, we operate the Cypress Center, a 16-bed acute psychiatric residential treatment program that serves as one of the three remaining designated receiving facilities for adults in New Hampshire. Our division of Emergency Services/Crisis Stabilization & Interim Care (ES) provides 6,000+ crisis evaluations and emergency interventions at the emergency departments of two community hospitals, the Elliot Hospital and Catholic Medical Center. ES operates 24/7 and offers a daytime/evening walk-in center along with follow-up crisis stabilization services and interim outpatient care. For persons experiencing crisis in the community, MHCGM’s Mobile Crisis Response Team (MCRT) provides an immediate response through the deployment of mental health clinicians and peer support and recovery coaches. In addition, our newly created Intensive Treatment Team ensures care transitions for at-risk individuals in need of community resources per social determinants of health. MHCGM also operates three residential programs as well as offering the following:
- Assertive Community Treatment Team (ACT)
- Case management/recovery/resiliency services
- Child and adult services
- Housing Outreach Team
- InSHAPE Healthy Choices/Healthy Changes program
- Medication services
- Senior counseling
- Vocational services
- Care transition services
- Substance use disorder services
- Medication assisted recovery (MAR)
Implementation of the Zero Suicide Framework
In early 2017, MHCGM set the implementation of the Zero Suicide framework as a priority based on feedback from agency staff and family members of clients. Later that year, seven MHCGM team members attended the Zero Suicide Academy, which prompted the creation of an agency-wide Zero Suicide Implementation Team in January of 2018. The team began to implement the Zero Suicide Plan and the Herth Hope Scale, and our president and CEO formally announced a call to action. From there, MHCGM’s Zero Suicide Committee began to discuss and implement specific steps pertaining to the seven pillars of the initiative: Lead, Train, Identify, Engage, Treat, Transition, and Improve (Figure 1).
Figure 1. MHCGM Zero Suicide Initiative
As those pillars suggest, changes to our organization have occurred—and will continue to occur—at every level, from scheduling staff protocols to service delivery. In an effort to ensure agency-wide implementation, position-appropriate trainings are required of all staff, including the following:
- Connect Suicide Prevention/Intervention
- Foundations of Zero Suicide: Clinical Competency
- Safety Planning
- Counseling on Access to Lethal Means (CALM)
- Dialectical Behavioral Therapy (DBT)
- Columbia-Suicide Severity Rating Scale (C-SSRS)
These trainings have resulted in increased awareness of risk factors and warning signs, which inform personal interactions with clients, families, and community supports, as well as treatment decisions. Both clinicial and nonclinical staff are actively identifying warning signs wherever present and referring as necessary.
Among other alterations, our electronic medical record (EMR) system now includes a client suicide risk console viewable to clinicians, which allows universal awareness of suicide risk and appropriate interventions and planning to prevent death by suicide. Additionally, warm hand-offs and caring contacts have been implemented as a structural component to our Acute Care Services, including Emergency Services and Interim Care, the Cypress Center, and the MCRT, which deploys with the Manchester Police Department (MPD) to diffuse crises in the community. And because MPD interacts with MHCGM clientele, its officers receive Crisis Intervention Training (CIT) so as to better mitigate situations—to the benefit of all parties involved.
Once a level of suicide risk and condition is identified, chronic or acute, appropriate intervention is initiated per the Risk Stratification Table. Re-assessment, safety planning, caring contacts, and follow-up appointments are planned by the clinician as indicated.
“At MHCGM, Zero Suicide has created an “all hands on deck” mindset to ensure that people who put their trust in us will experience that we are laser focused on their safety and their recovery.”
– William Rider, President and CEO of The Mental Health Center
Screening
Because MHCGM provides various levels of care at multiple locations via office-based and community-based teams, suicidal risk is identified and assessed through screening, assessing, and risk formulation early and often. We use the Patient Health Questionnaire (PHQ) and the Columbia-Suicide Severity Rating Scale (C-SSRS) at any visit where risk is identified, as well as for the following:
- All emergency services visits, both in the Emergency Department and in the office
- All emergency services visits and Emergency Department discharges to home after extended stay
- All MCRT visits and MCRT apartment discharges
- At the Cypress Center Inpatient Unit during stay and prior to discharge (Discharge Screener version)
- At any visit (including intake) when the PHQ-3, PHQ-9, or PHQ-A is positive. For example, if an individual scores positive on question 9 on PHQ-3 and/or scores in the moderate range or higher on PHQ-9, then the C-SSRS must be done.
- For children under 7 years old or an individual with intellectual disabilities, we use the C-SSRS Very Young Children full screen version.
If suicide risk is identified, a comprehensive assessment must be conducted and an action plan developed. A safety plan is completed with anyone who demonstrates risk but is not in need of immediate rescue and a copy of the safety plan is kept in the record.
Assessment
Every client assessed to have suicidal risk receives a suicidal care management plan or pathway to care that is both timely and adequate to meet his or her needs. All nonclinical staff and ancillary team members, upon contact with a client who communicates suicidal thoughts by phone or in person, must immediately notify a clinical provider to provide support and assessment of the suicidal individual.
Effective suicide care management plans include consultation, collaboration, and coordination among MHCGM staff, family/support system, and other care providers. Strategies to promote continuity of care are implemented to address those periods of highest risk, particularly for individuals who are difficult to engage in treatment. Strategies may include increased frequencies of contacts, referral to the Care Transition Team or Intensive Transition Team, MCRT, follow-up, peer support involvement, engagement support and any other measures to network, provider communication to ensure safe transitions (i.e., warm handoffs).
All suicide prevention documentation is contained in the risk console within our EMR system.
High acute risk: Individuals experiencing high acute risk for suicide typically require psychiatric hospitalization to maintain safety and aggressively target modifiable factors. These individuals need to be directly observed until they are on a secure unit and then located in an environment with limited access to lethal means (e.g., keep sharps, cords/tubing, and toxic substances away from these clients). During hospitalization co-occurring psychiatric symptoms should also be addressed.
Intermediate acute risk: Individuals experiencing intermediate acute risk for suicide may require psychiatric hospitalization if related factors driving the risk are responsive to inpatient treatment (e.g., acute psychosis). Outpatient management of suicidal thoughts and/or behaviors should be intensive and include the following:
- Increased and frequent contact
- Regular re-assessment of risk
- A well-articulated safety plan
- Warm hand-off (live communication between care providers)
- Release of Information to support system to maintain collateral contact
Mental health treatment should also address co-occurring psychiatric symptoms.
Low acute risk: Individuals experiencing low acute risk for suicide, require outpatient management of suicidal thoughts and/or behaviors. Outpatient behavioral health/primary care may also be indicated, particularly if suicidal ideation and psychiatric symptoms are co-occurring.
Safety Planning
We use the Safety Planning Intervention developed by Stanley and Brown. 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.
When a client is evaluated and subsequently released to the community (i.e., not hospitalized), the assessing clinician coordinates an outreach call/caring contact within the following 72 hours to ascertain the client’s current status. Transitions in care include discharge from hospitals, including but not limited to the emergency department, or any situation in which a person at risk of suicide is between care providers.
Data and Key Outcomes
With regards to data collection, MHCGM has implemented a Quality Improvement Plan—carried out through all departments, programs, committees, work groups, and teams—where performance measures are analyzed for the stability of the process, the level of overall performance, comparison to other organizations, and the level of performance relative to our goal for performance. For our Zero Suicide implementation, data is collected across our agency and is ever-evolving. All trainings are recorded by our Continuing Educations Departments. Other information, including deaths by suicide, emergency department diversion rates, PHQ/C-SSRS ratings, and subsequent safety plans completed, etc., are currently being assessed for compilation into a Zero Suicide dashboard that will inform our targets for improvement. While we are early in the process of implementing Zero Suicide, we have collected the following data: 2018 marked our first full year of the Zero Suicide implementation. Below is the outcome data collected (see Table 1).
Table 1. Outcome Data
| OUTCOMES | 2015 | 2016 | 2017 | 2018 |
|---|---|---|---|---|
| Suicide rate (MHCGM’s % of NH’s death by suicide) | 3.5% | 3.8% | 3.1% | 1.8% |
| MHCGM DBT Program deaths by suicide | 0 | 0 | 0 | 0 |
| Percentage of staff who have received suicide prevention training | 1.8% | 3.9% | 6.3% | 80% |
|
Mobile Crisis Response Team Emergency Dept diversion rate |
N/A | N/A | 90.3% | 94% |
“We want our data to give reassurance to those who put their trust in us that MHCGM is suicide safe zone”
– William Rider, President and CEO of The Mental Health Center
Suicide Rate
While New Hampshire experienced a 6.6% increase in suicide rate from 2017 to 2018, deaths by suicide for our agency serves decreased significantly following our first full year of Zero Suicide implementation. Further, MHCGM experienced a 44% decrease in death by suicide for people in active treatment. It is important to note that Manchester constitutes NH’s diverse urban heart and is a federally designated resettlement zone. On average, data shows Manchester experiences poorer outcomes than 500 similarly urban areas, including but not limited to, elevated poverty rates, unemployment rates, and the rate of uninsured.
Training
Our region’s reduction in deaths by suicide can be attributed, in part, to MHCGM’s commitment to suicide prevention/intervention/postvention training. As of 2018, 80% of both clinical and nonclinical staff have received position-appropriate Zero Suicide-related training, including the following:
- Zero Suicide Foundations
- Connect Suicide Prevention/Intervention
- Counseling on Access to Lethal Means (CALM)
- Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP)
- Columbia-Suicide Severity Rating Scale (C-SSRS)
And because MHCGM is a regional leader in the evidence-based practices of Dialectical Behavioral Therapy (DBT), the suicide rate for clients receiving DBT has remained zero.
Diversion Rate
Since 2016, MCHGM has offered an MCRT that provides 24/7 emergency response directly to the individuals affected through the deployment of mental health clinicians and peer support/recovery coaches alongside the MPD. Since its inception, MCRT has served thousands of individuals, providing tens of thousands of services to individuals aged 5 to 96, with an average response time of 16 minutes. Currently, MCRT’s diversion rate away from the hospital emergency department and to appropriate mental and behavioral health services is 94%. In addition, our work with the MPD has led to the implementation of Crisis Intervention Training (CIT), which is designed to develop and encourage the strategic communication of police officers when responding to individuals experiencing mental and behavioral health challenges, thereby lessening incidences of force and reducing risk of injury. CIT has revolutionized police and public interactions here in Manchester. Currently, MPD has approximately 75 CIT-trained officers. Anecdotally, MPD’s Patrol Sargent and MHCGM liaison recently stated to an NH expert reviewer that if MCHGM involvement with CIT and Mobile Crisis Response were to ever cease to exist, he would quit on the spot. MHCGM’s impact on the community, hospital diversions, suicide response and reduction, and overall cost savings for fire and safety is immense.
Future Steps
Suicide-related trainings will continue for existing staff, and are required of incoming staff per our agency’s continuing education programming. It is the intention of MHCGM to re-issue the Zero Suicide workforce survey to gather comparison data around the impacts of trainings and staff competency and confidence in treating individuals experiencing suicidal ideation. Such data will help our organization better target areas of training that will help our community achieve the ambitious goals of Zero Suicide. In fact, MHCGM’s president and CEO recently issued a CEO’s challenge “to think about data from a mindful leadership approach to improve outcomes.” Consequently, we are working across our agency to ensure that all data is compiled intentionally and with purpose in order to drive positive change in the delivery of care. Tracking the number of caring contacts, average response times, and client satisfication particular to this initiative will undoubtedly help all members of our community.
Because the targets of Zero Suicide require community investment, our Emergency Services & Interim Care Department will use its participation in the Manchester Shared Emergency Response System to influence coordinated care around suicide prevention and the creation of suicide safe environments. As an integrated behavioral health partner in our community, MHCGM has opportunities to engage other providers in Zero Suicide implementation and is committed to doing so whenever and wherever possible. As we continue our efforts to reduce suicide in our community, it will be helpful to track which of our community partners are also implementing the principles of Zero Suicide so we can share information to ensure continuity across the continuum of care. Such partnerships include collaboration with the Manchester VA, joint C-SSRS trainings with Elliot Health Systems and Catholic Medical Center, as well as PHQ-9/Suicide Prevention training with NH’s Integrated Delivery Network partners to ensure a clear chain of referral from primary care.
Lastly, to further our community’s Zero Suicide implementation efforts, CIT trainings and recertifications are scheduled twice annually for Manchester police officers and for officers of surrounding areas. While MPD data analytics have yet to exist, officer anecdotes suggest that they now spend less time on mental health calls and feel more confident responding to calls when necessary.
Authorship Details
- Patricia Carty, MS, CCBT; Executive Vice President/Chief Operating Officer
- Kristen Kraunelis, RN, BC, LICSW; Director of Quality Improvement
- Nathan Fink, Per Diem Grant Coordinator
For more information, contact Patricia Carty at cartypat@mhcgm.org or Kristen Kraunelis at kraunelk@mhcgm.org.