The Missouri Department of Mental Health has provided leadership for Zero Suicide implementation in the state since 2014. It subsequently engaged each of the state’s community behavioral health centers (CBHC) in Zero Suicide by offering multiple consultation opportunities with Zero Suicide experts and by leading and developing a robust learning collaborative.
Key Outcomes:
- From 2015 to 2017, there was a 32% decrease in suicide deaths among clients served in Community Behavioral Health Centers.
- Over 85% of the CBHC’s made improvements in the Zero Suicide Organizational Self-Study scores at second administration.
Statewide Support for Implementing Zero Suicide:
Missouri Department of Mental Health has participated in the Zero Suicide initiative since June 2014, when a team representing the Missouri Department of Mental Health applied and was selected to attend the Zero Suicide Academy. The Zero Suicide Academy® is EDC's signature two-day training for senior leaders of health and behavioral health care organizations that seek to dramatically reduce suicides among patients in their care. The Zero Suicide Academy provides Zero Suicide implementation teams the opportunity to learn from Zero Suicide Institute experts, receive implementation consultation, and begin strategic planning for Zero Suicide initiatives. Missouri was one of sixteen states chosen to attend the first Zero Suicide Academy that was held in Washington, D.C. A team from the Department’s Chief Medical Directors office and a representative from a community provider attended the first year. After attending the Zero Suicide Academy, these suicide prevention champions were eager to spread their knowledge to others in order to reduce suicide deaths in Missouri.
These champions helped to push this work forward by creating a 90-day plan for statewide implementation of the Zero Suicide model. This plan included a formal recommendation to Department of Mental Health’s Administration for implementation of Zero Suicide within the State’s Behavioral Healthcare System.
Once administrative support was achieved; the next step was to present this recommendation to the Coalition for Community Behavioral Healthcare member agencies and encourage teams to apply for the second Zero Suicide Academy. The Missouri Department of Mental Health’s Division of Behavioral Health divides Missouri into twenty-five service areas. Each area has a community behavioral health center (CBHC) which provides psychiatric services to individuals in need. It is designated as the Division’s Administrative Agent. The Coalition, represents the Administrative agents as well as affiliated community psychiatric rehabilitation service providers, and a clinical call centers. Administrative Agents serve as the primary entry and exit points for state mental health services and are responsible in their assigned areas for assessment and services for both adults and children and for providing follow-up services for individuals released from state-operated inpatient hospitals. The Department of Mental Health assisted by supporting the agencies and providing technical assistance during the application process.
Community Behavioral Healthcare Centers:
The Missouri Coalition for Community Behavioral Healthcare Providers Board committed to adopting Zero Suicide as one of their key initiatives after being introduced to the model at their 2015 annual conference. After partnering with the Coalition of Community Behavioral Healthcare Providers, Department of Mental Health funding was made available to bring the Zero Suicide Academy to Missouri. In April 2016, over half of the Coalition member agencies, totaling 17 agencies, sent teams to the Zero Suicide Academy held in Jefferson City, Missouri. The following year, 2017, the Zero Suicide Academy was brought back to Missouri. A total of 14 agencies, including the remaining half of the contracted community treatment providers, attended this academy—making Missouri the first state to train all of its contracted treatment providers in Zero Suicide.
Zero Suicide Academy Cohorts:
| Cohort 1 (2014 & 2015 attendees) | Cohort 2 (2016 attendees) | Cohort 3 (2017 attendees) |
|---|---|---|
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Learning Collaboratives:
In order to sustain momentum, Department of Mental Health is continuing its collaboration with the Missouri Coalition for Community Behavioral Healthcare. The department is also consulting with Dr. Bart Andrews, vice president of clinical practice/evaluation at Behavioral Health Response, Zero Suicide Faculty member, and SPRC Steering Committee member, to provide ongoing training and technical assistance in the form of quarterly learning collaboratives to all Zero Suicide Academy attendees. Each year, two of these collaboratives are held via webinar/conference call, while the other two are in-person/day-long sessions. The collaboratives consist of state and federal suicide prevention updates, agency report outs, training or technical assistance often with guest speakers, and information sharing opportunities. Agency report outs include progress and barriers to implementing the Zero Suicide Framework in their respective agencies which can provide validation, brainstorming, and learning opportunities for attendees. Technical assistance or trainings are based on ideas and feedback from the groups. Some trainings we have provided in the past include: Crisis Response Planning by Craig Bryan, assistant professor of clinical psychology at the University of Utah; Legal Aspects of Suicide Prevention by attorney Skip Simpson; a presentation on Dialectical Behavior Therapy by Becky Stoll, vice president of Crisis Disaster Management at Centerstone and Zero Suicide Faculty member; and Post-Suicide Communication for Clinicians and Agencies by Dr. Bart Andrews. All feedback from attendees has been positive and we have had very good attendance from throughout the state.
Missouri State-wide Outcomes:
The Department of Mental Health has supported the adoption of the Zero Suicide approach amongst Missouri’s mental health agencies. Through adoption of the Zero Suicide approach, agencies are improving care and outcomes for individuals at risk of suicide in health care systems. This approach represents a commitment to patient safety and to the safety and support of clinical staff, who do the often demanding work of treating and supporting suicidal patients.
As shown in the data below, the number of suicide deaths appears to decrease as the number of agencies trained in the adoption of the Zero Suicide Model increases. From 2015 to 2017, there was a 32% decrease in suicide deaths amongst clients served through Community Behavioral Healthcare Providers.
| Suicide Deaths Among Department of Mental Health Division of Behavioral Health Providers | |||
|---|---|---|---|
| Fiscal Year | 2015 | 2016 | 2017 |
| # of DBH providers that attended a Zero Suicide Academy | 2 | 17 | 14 |
| # consumers served by DBH | 120,680 | 118,036 | 120,183 |
| # of DBH consumer suicide deaths | 108 | 92 | 73 |
| Suicide rate per 1,000 served | 0.9 | 0.78 | 0.61 |
After attending the Zero Suicide Academy all agencies completed the Zero Suicide Organizational Self-Study and the Zero Suicide Workforce Survey. To assess progress to date, a total of twenty-eight community agencies have completed a second survey. Below are some results from this survey that serve as concrete examples of how to put the Zero Suicide framework into action in the field.
- Twenty-seven of the twenty-eight agencies have adopted written processes related to three or more components of the Zero Suicide Model while one agency has adopted formal, but not written processes.
- Twenty-seven of the twenty-eight agencies have developed written protocols for screening for suicide.
- Twenty-four of the twenty-eight agencies have embedded screening for suicide risk in their electronic health records (EHR).
- Twenty-six of the twenty-eight agencies provide staff training on screening for suicide risk.
- Twenty-six of the twenty-eight agencies have policies related to assessment and train staff on assessment processes.
- Twenty-five of the twenty-eight agencies have embedded a suicide risk assessment in their EHR.
“The learning collaborative has been a great tool for our agency to start the conversation around Zero Suicide, have a forum to hold us accountable in moving forward, and provide us a supportive group to nurture our progress and help us through any identified gaps and barriers we were facing.”
– Lauren Moyer, ReDiscover
Implementation at Two Missouri Community Behavioral Healthcare Centers:
Below are two case examples from Community Behavioral Healthcare Centers that partnered with the Department of Mental Health and implemented Zero Suicide at their organization.
Community Counseling Center:
About Community Counseling Center:
Community Counseling Center (CCC) is a not-for-profit behavioral health organization serving the public since 1974. CCC is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) International and is certified by the Missouri Department of Mental Health (DMH). We provide a full array of comprehensive behavioral health services within five southeastern Missouri counties: Bollinger, Cape Girardeau, Madison, Perry, and Ste. Genevieve. Approximately 387 professional and support staff operating from 18 separate locations provide services to nearly 6,500 distinct persons annually. At every level of operation, Community Counseling Center is dedicated to the treatment, support, and ultimate recovery of individuals living with mental illness.
Implementing Zero Suicide:
As part of our application to the Zero Suicide Academy, we completed the Zero Suicide Organizational Self-Study. After attending the Zero Suicide Academy in 2016, we replaced our no-show letters with care cards, which are much more person-centered and don’t sound punitive. We administered the Zero Suicide Workforce Survey to all staff, and the results helped us to create a staff training plan. We started educating all staff in suicide prevention appropriate to their role, and we started screening all outpatient consumers for risk of suicide at each session.
Support from the state learning collaborative:
The State Learning Collaborative has been helpful to feel like we are all part of a larger group - all Community Mental Health agencies in Missouri – and we are working on this at the same time. We have the opportunity to learn from each other’s successes and ideas, as well as hear about things that didn’t work out. We are even a little competitive sometimes, but realize we are all working together towards a common goal! The collaborative also holds us accountable, knowing we are checking in every three months, and has provided some great learning opportunities.
Next steps:
At Community Counseling Center, we are updating our electronic medical record (EMR) to help support the implementation of a suicide care pathway. These updates will allow us more flexibility with respect to having alerts and a way to track interactions with consumers who are on the suicide care pathway. This update will also allow us to automate the C-SSRS in our EMR system when a patient scores positively on question nine of the PHQ-9 (indicating the presence and duration of suicidal thoughts). This automation will help ensure that clinicians follow through with this important screening to assess the severity and immediacy of the patient’s risk for suicide in order to determine appropriate follow up. We are also updating policies and procedures to incorporate other elements of the Zero Suicide framework and to include trauma-informed care practices. Part of these updates include providing additional training to staff – the entire agency will be trained in Question, Persuade, Refer (QPR) training, some staff will attend Applied Suicide Intervention Skills Training (ASIST), and we also hope to have more clinicians attend Assessing and Managing Suicide Risk (AMSR) trainings. We believe in our statewide system of care, and we will continue to work to reach our goal of zero suicides.
ReDiscover:
About ReDiscover:
ReDiscover, a community behavioral health center, has a 49-year legacy of providing innovative, comprehensive and compassionate care to hundreds of thousands of people. On an average day, 2,000 individuals are served across 14 clinic locations that offer individual, group and family therapy; psychiatric evaluation and rehabilitation; supportive housing; medication management; crisis intervention; acute day treatment; psychosocial and residential substance use disorder services; health assessment and coordination; and on-site pharmacy and laboratory services.
ReDiscover serves Jackson County and surrounding areas. The majority (84%) of ReDiscover patients have incomes below the federal poverty level and many do not have Medicaid, Medicare or private insurance. Jackson County encompasses much of the city of Kansas City and also contains 16 other municipalities. With 687,000 residents, it is the area’s population center.
Implementing Zero Suicide
In 2016, ReDiscover completed the Zero Suicide Organizational Self-Study and attended a Zero Suicide Academy. From there, we began implementing Zero Suicide by communicating with staff about the Zero Suicide framework and our results from the Zero Suicide Organizational Self-Study. Other activities we did to kick off implementation included:
- Developing a Zero Suicide Agency workgroup comprised of a vertical staff representation from facility, HR, IT and clinical staff to implement action items from the Zero Suicide Organizational Self-Study
- Implementing screenings including the PHQ-9 and the C-SSRS
- Developing an Enhanced Care Protocol for those who were identified to be a moderate to high risk of suicide.
Outcomes:
- We now screen 90% of our clients on a routine basis, whereas prior to Zero Suicide implementation we may have routinely screened 25%.
- Three-quarters (74%) of our Medication Clinic clients had a decrease in PHQ-9 score from their initial Psychiatric Evaluation to 6 months after their initial service.
- There was a 44% decrease in depression severity for individuals who scored a 10 or higher on the PHQ-9 from the first Medication Clinic appointment to the service 6 months after the initial service.
- The mean PHQ-9 score decreased from 10.8 at the initial appointment to 7.2 at the 6-month appointment, a statistically significant change.
We have also rolled out QPR training for all levels of agency staff (clinical and non-clinical) and we are beginning to provide ASIST training as we have two internal staff who recently became trainers.
Support from the state learning collaborative:
The learning collaborative has been a great tool for our agency to start the conversation around Zero Suicide, have a forum to hold us accountable in moving forward, and provide us a supportive group to nurture our progress and help us through any identified gaps and barriers we were facing.
Next steps:
We are continuing to work on mastering our process for PHQ-9, C-SSRS and Enhanced Care Protocol amongst all clinical programs and at all locations. We are also continuing to work on an ongoing staff development process within each program for staff to have the tools they need and to be comfortable in asking the questions related to suicide risk. We continue to work on addressing stigma both internally and externally about asking someone if they are having feelings of wanting to kill themselves and that it’s okay to talk about it.
Authorship Details
- Stacey Williams, LMSW, CCDP, CGDC, State Suicide Prevention Coordinator, Missouri Department of Mental Health
- Lauren Moyer, LSCW, LCSW, Vice President of Clinical Services, ReDiscover
- Rick Strait, MS, LPC, CRDAC, ITCD Program Manager and Suicide Prevention Coordinator, Community Counseling Center
For more information contact Stacey Williams at Stacey.williams@dmh.mo.gov