Patients at risk for suicide agree to actively engage in a package of evidence-based practices that directly targets their suicidal thoughts and behaviors.
Overview: Suicide Care Management Plan
When an organization makes a commitment to Zero Suicide, every patient who is identified as being at risk for suicide is closely followed through a suicide care management plan or a pathway to care. It is essential to continuously assess risk, engage patients in their collaborative safety plan, treatment plan, and suicide care management plan and re-engage patients at every encounter, no matter what the reason for the visit.
All staff members have crucial roles in preventing suicide. A fundamental premise of the Zero Suicide approach is that safer suicide care begins from the moment a patient calls the organization for an appointment, is assessed, or is admitted for treatment, whichever comes first. Suicide risk immediately becomes a primary focus of assessment in a behavioral health or primary care setting if a patient indicates current or past suicidal thoughts or attempts or is identified as at risk through screening.
Evidence shows that outpatient management of suicidal patients can be safe, clinically appropriate, and, at times, preferable to inpatient care.1 Patients at high risk of suicide are often among the highest percentage of those dropping out of treatment.2 The Joint Commission recommends motivational enhancement strategies to increase the likelihood of engagement in further treatment.3 Improvements in treatment compliance for patients at risk for suicide can be obtained through intensive follow-up, case management, contacts, and visits.1 Research shows that improved ease of access to emergency services can reduce subsequent attempts by those who have made their first suicide attempt.1 ,3
Several studies have shown that engaging patients by beginning interventions and treatment at or as soon as possible after emergency room or inpatient discharge has demonstrated significant reductions in repeat suicide attempts.4 The risk of a suicide attempt or death is highest within the first month after discharge from inpatient or emergency department care.4 Particularly high-risk periods are the first week and the first day after discharge.4 ,5 47 percent of those who died by suicide following discharge died before their first follow-up appointment, and 43 percent of suicides occurred within a month of discharge.5 Up to 70 percent of patients who leave the emergency department after a suicide attempt never attend their first appointment.6 The average performance was only 51 percent on the Healthcare Effectiveness Data & Information Set (HEDIS) measure for one completed outpatient visit within seven days of discharge from inpatient psychiatric hospitalization.6 ,7
Recommendation: Develop a Pathway to Care
Care protocols for patients with high suicide risk are similar to systematic approaches used for other health conditions, such as diabetes or high blood pressure. One protocol for ongoing engagement is a suicide care management plan, also called a pathway to care. Establishing a suicide care management plan involves changes in systems and requires staff buy-in. Implementation policies, outlined in the Zero Suicide Toolkit, include establishing:
- A screening tool, as outlined in the Identify element of Zero Suicide, and criteria to indicate that a patient should be engaged in a suicide care management plan
- Same-day access to behavioral health professionals for those determined to be at immediate risk through the use of a standard risk formulation framework
- Requirements and protocols for safety planning, crisis support planning, and lethal means reduction, including the frequency of visits and actions to be taken if a patient misses appointments or drops out of care
- Channels for communicating with a patient about diagnosis, treatment expectations, and what it means to have a suicide care management plan
- A referral process to suicide-specific, evidence-based treatment and requirements for continued contact, especially during transitions in care
- Criteria and protocols for closing out a patient’s suicide care management plan
- Training for all staff at least annually in suicide care management plan policies and protocols and documentation requirements so that they understand the reason for these policies and what is expected of them
- A schedule for regular team meetings and clinical case consultations to discuss patients at risk for suicide
- A schedule for management to regularly review charts to determine that policies and protocols are followed
Conclusion: Engage and Assess at Every Opportunity
Current research suggests that no single approach will reduce suicide among individuals who are in care. Comprehensive, multi-component, system-wide approaches to suicide prevention have been shown to be effective in broad and diverse settings and likely are the keys to reducing suicide.4 ,5 ,6 ,7 The Zero Suicide approach offers a toolkit that guides implementers in the process of embedding interconnecting evidence-based practices for suicide prevention into health care systems.
Engage: Safety Planning
Safety planning is an essential intervention and component of an effective and evidence-based suicide care management plan.
Overview: Collaborative Safety Planning
Safety planning is an essential intervention with individuals at risk for suicide. It can be done in a variety of settings including emergency departments, primary care, and mental health and is a key component of an effective and evidence-based care management plan. It can be used with individuals who have made a suicide attempt, experience suicidal ideation, or are determined to be at risk for suicide.8 ,9 Safety planning is not be confused with contracts for safety or no-suicide contracts. There is no evidence that these contracts are effective, and they can provide a false sense of security for the provider.8 ,10 Crisis response planning or safety planning have been found to be more effective than a contract for safety.8 ,11
Safety planning is a brief intervention involving a prioritized list of coping strategies and supports developed collaboratively between an individual and a clinician. Often, individuals at risk for suicide who are not admitted to treatment by emergency departments or crisis services are referred to outpatient mental health treatment. It is likely that the patient will continue to struggle with suicidal thoughts or emotional crises. The safety plan is an intervention to provide patients with a set of specific, concrete strategies tailored to their individual needs and circumstances that they can use to decrease the risk of suicidal behavior and increase treatment motivation and compliance.12 ,13 Safety plans incorporate elements of several evidence-based suicide risk reduction strategies that are a part of the Zero Suicide approach, including means reduction, brief problem-solving and coping skills, social and emergency crisis support, and motivational enhancement for treatment.12 ,13
Recommendation: Engage a Safety Plan
The elements of a safety plan are as follows:9
- Warning Signs - Recognition of the signs that immediately precede a suicidal crisis
- Internal Coping Strategies - Things patients can do to distract themselves without contacting anyone
- Social Situations That Can Help Distract Me - Places patients can easily access that provide a safe environment (a library, mall, coffee shop, etc.)
- People I Can Ask for Help - At least three support persons; persons who are available, able to provide support, aware of resources, and informed that they are a part of the safety plan
- Professionals or Agencies I Can Contact During a Crisis - Professionals and crisis support agencies including the hours and contact information for current treatment provider, local and regional crisis support, and national crisis support providing 24/7 crisis services
- Making the Environment Safe - Steps to remove access to lethal means, strategies to limit or eliminate substance use, and any other strategies to maintain a safe environment
Research shows that individuals with higher-quality safety plans are less likely to be hospitalized in the year after safety planning.8 ,14 Interviews with 100 veterans in a qualitative study found that 97 percent were satisfied with their safety plan, 61 percent reported using their plan, and 20 percent reported making changes to their safety plan on their own or with a professional. For those using the safety plan, the aspects that veterans reported were most helpful included social contacts, places for distraction, social support for crisis help, contacting professionals, and internal coping strategies.14 ,15 A recent study found that crisis planning reduced suicide attempts, reduced inpatient hospitalization, and was associated with a faster decline in suicidal ideation in high-risk active duty soldiers.11
After a comprehensive risk assessment, safety plans are developed collaboratively with the individual at risk for suicide using a problem-solving approach that addresses barriers and explores the likelihood of use. Loved ones and others explicitly mentioned in the safety plan should be educated about their role and responsibilities should the individual come to them for support.
Staff and providers must be trained in creating safety plans, engaging the individual at risk for suicide and any necessary support persons, and documenting and following up on the safety plan. It is important to follow up and conduct internal reviews of staff use of safety planning interventions to determine effectiveness, consistent application, and fidelity of this evidence-based practice, and the need for additional staff training or education.8 ,9 ,12 ,16
Conclusion: Collaborate for Accountable Care
Safety planning emphasizes collaboration between a patient and clinician and operationalizes continuity of care. As one emergency department psychiatrist reported, “I am very satisfied, but partly because [safety planning] helps facilitate my clinical role as an urgent care psychiatrist in that it provides a bridge between the emergency care and outpatient treatment.”15 Research demonstrates that effective safety planning has positive outcomes for patients and patient care management.
Engage: Reducing Access to Lethal Means
Reducing access to lethal means is an essential step in safety planning.
Overview: Reducing Access to Lethal Means Works
A key component of Zero Suicide and other effective suicide prevention strategies is reducing access to methods that could be used for suicidal acts and, if possible, restricting access during an acute suicidal crisis. Reducing access to lethal means—particularly those with greater lethality—is essential in safety planning.
Studies around the world have demonstrated that the overall rate of suicide drops when access to commonly-used, highly lethal suicide methods is reduced.17 ,18 ,19 In the late 1950s, the United Kingdom switched from coal gas to natural gas, which is free from carbon monoxide.17 Suicide deaths decreased, saving thousands of lives over the next 10 years. A study in Australia found a decrease in suicide by firearms and in the overall national suicide rate following a 1998 ban on private gun ownership.19
Every safety plan should address reducing access to any lethal means that are available to the patient. Limiting access to medications and chemicals and removing or securing firearms, other weapons, and ligatures are important actions to keep patients safe. This is particularly important in light of findings about the impulsivity of many suicide attempts. Among people who made near-lethal suicide attempts, 24 percent reported taking less than five minutes between the decision to kill themselves and the actual attempt. 70 percent took less than an hour.20
Based on this evidence, it is clearly possible to increase the chance of surviving an attempt if an individual at risk for suicide has reduced access to lethal means in their moment of crisis. This also has longer-term implications for these individuals. 90 percent of individuals who attempt suicide will not go on to die by suicide at a later time.21 Even with underlying or chronic risk factors, a person’s suicidal crisis is often of short duration and a treating team can significantly help an at-risk individual by limiting access to lethal means.17 ,22 Additional evidence supports that availability of method influences choice of method. If a favored method becomes less available, individuals do not necessarily engage in means substitution.22
Recommendation: Establish Specific Protocols and Effective Policies
Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with an individual at risk for suicide. The Counseling on Access to Lethal Means (CALM) online training is offered free of charge by the Suicide Prevention Resource Center.23 The training is designed to increase knowledge of the association between access to lethal means and suicide and the role of means restriction in prevention. The course is also intended to increase a provider’s skills and confidence to assess and reduce a patient’s access to lethal means.
Research shows that mental health providers demonstrated an increase in knowledge and skills regarding lethal means reduction counseling and sustained change in beliefs and attitudes about the importance of lethal means restriction following a CALM training.23 At a 6-week follow-up from a CALM training, 65 percent of providers reported already counseling on means reduction.24
As a part of the Zero Suicide approach, it is recommended that this training—paired with site-specific policies about reducing access to lethal means—be required of all clinical and, in some cases, non-clinical staff members.
Specific attention should be paid to protocols about reducing access to firearms. Firearms are the most common method of suicide in the U.S., and more people die by suicide via this method than all other methods combined.17 Every U.S. study that investigated the relationship between firearms and suicide has found that access to firearms is a risk factor for suicide.17
Organizational policies should clearly state what clinicians are expected to do regarding lethal means. Policies should include the protocol to follow in the event that a patient brings a weapon or other lethal means into a clinical setting. Policies and training should reflect specific steps that clinical and non-clinical staff can take to reduce access to lethal means. These include the process for securing weapons and medications and the conditions under which they may be returned.
Conclusion: Reducing Access to Lethal Means is an Essential Step
It is essential to assist patients through a crisis by actively engaging them to reduce their access to lethal means. Engagement also means developing an individualized collaborative safety plan, encouraging active participation in treatment, and providing patients with a clear roadmap to their care. Using these approaches, clients are more likely to get through their short-term suicidal crisis safely and experience long-term recovery.
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