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Service Delivery Innovation Profile

Emergency Departments Identify and Support Veterans at Risk of Suicide, Enhancing Their Access to Outpatient Mental Health Services


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Snapshot

Summary

Through the Suicide Assessment and Follow-Up Engagement: Veteran Emergency Treatment (more commonly referred to as SAFE VET) initiative, emergency departments at Veterans Affairs hospitals identify veterans at risk of suicide who do not require immediate inpatient care and intervene to reduce that risk. An emergency department–based staff member develops a customized safety plan (known as the Safety Planning Intervention) to cope with suicidal urges, and then provides a structured followup intervention by telephone after discharge to assess current risk; review and revise the safety plan if necessary; enhance motivation to seek treatment; and promote connections to outpatient care and community-based support, including removing obstacles to accessing such care and support. The intervention has enhanced access to outpatient mental health services for veterans at risk of suicide and has generated positive feedback on acceptability and effectiveness from patients and emergency department–based clinicians. Ongoing research is more rigorously analyzing the program’s impact on key metrics, including suicide attempts.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of the number of outpatient mental health visits attended by participants during the 6-month period before and after receiving program services. Additional evidence includes post-implementation data on the proportion of participants accessing mental health services within 2 weeks and 6 months of their initial ED visit, along with feedback from patients and clinicians on their satisfaction with the program.
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Developing Organizations

U.S. Department of Veterans Affairs
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Use By Other Organizations

Some other EDs have adopted the Safety Planning Intervention component of this program, but few have combined it with the post-discharge outreach and support.

Date First Implemented

2009
The initial demonstration project ran from September 2009 until October 2012.begin pp

Patient Population

Vulnerable Populations > Military/dependents/veteransend pp

Problem Addressed

Suicidal individuals frequently use the emergency department (ED) as their primary or sole point of contact with the health care system. However, most EDs have limited expertise in assessing risk or helping these patients reduce the risk of suicide.
  • Heavy reliance on EDs: Suicidal individuals often use the ED as their primary or sole source of care.1,2 Contact with the ED often occurs either immediately after a suicide attempt or when suicidal thoughts escalate to a level that the individual feels in danger of acting on these thoughts. The risk of suicidal behavior can be particularly high right after contact with acute psychiatric services for suicide-related services.3 During this period, it can be especially difficult to provide continuity of care.4,5
  • Ill-prepared to assist: In most EDs, busy clinicians and staff do not have the time, resources, or expertise to identify and provide optimal assistance to suicidal individuals. In many cases, signs of suicidal risk are missed, and when they are not, patients typically end up being admitted to the hospital (if risk is high) or referred to community-based practitioners and resources (if risk is less severe), with no risk-reducing interventions taking place in the ED itself or followup occurring after discharge. In the majority (60 to 90 percent) of cases, individuals referred to community-based resources do not end up accessing them.6

What They Did

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Description of the Innovative Activity

Through SAFE VET, EDs at Veterans Affairs (VA) hospitals identify veterans at risk of suicide who do not require immediate inpatient care and intervene to reduce that risk. An ED-based staff member develops a customized safety plan (known as the Safety Planning Intervention7,8) to cope with suicidal urges, and then provides structured followup support by telephone after discharge to assess current risk; review and revise the safety plan if necessary; enhance motivation to seek treatment; and promote connections to outpatient care and community-based support, including removing obstacles to accessing such care and support. Key program elements are outlined below:
  • Clinician assessment to determine risk, appropriate next step: As a part of routine care, nurses conduct a standard, primary evaluation and physicians conduct a follow-on assessment to determine the patient’s level of risk for suicide. Based on these assessments, the clinicians decide on the appropriate next step, including whether the patient could benefit from SAFE VET, as outlined below:
    • Hospitalization for most high-risk patients: Most patients identified as being at high risk are immediately hospitalized.
    • Referral to outpatient and related services for most low-risk patents: Most patients identified as being at low current risk of suicide receive information on available VA outpatient mental health and related services, including the VA Crisis Line.
    • Referral to SAFE VET, primarily for moderate-risk patients: Generally, patients considered to be at moderate risk of suicide qualify for SAFE VET. In some cases, an individual currently at low or high risk may qualify as well. For example, an individual who has ill-defined, passive suicide ideation and no current risk factors might be considered low risk but still could benefit from and hence be referred to SAFE VET. Similarly, someone who has attempted suicide in the past or endured major life stressors but does not require hospitalization might fit the same profile. In other words, some individuals considered to be at high risk but not in need of immediate hospitalization may be referred to SAFE VET.
  • ED-based support from acute services coordinator: Patients deemed appropriate for SAFE VET immediately meet with an ED-based acute services coordinator who introduces the program and gauges their interest. During the initial demonstration project, 93 percent of patients (438 out of 471 veterans) agreed to receive the intervention.6 For those who do, the coordinator spends approximately 20 to 40 minutes working with the patient to complete a customized Safety Planning Intervention,7,8 a structured tool that identifies the individual’s distinctive warning signs for suicide and describes tailored, practical strategies for dealing with these signs when they appear. As outlined below, these strategies are laid out hierarchically, beginning with things the individual can do on his or her own and then successively bringing in additional sources of support as necessary.
    • Self-coping strategies: First-level strategies lay out specific things the individual can do to cope with a developing suicide crisis, such as engaging in preferred activities to take his or her mind off of problems (e.g., taking a walk, playing a video game, listening to calming music, meditating, praying). As part of the process of developing this list, the coordinator introduces and teaches brief problem-solving and coping skills to the individual.
    • Social distractions: If the initial self-coping strategies do not suffice, the patient is instructed to move to a second-level set of strategies that focus on accessing preferred social contacts who can engage and distract the individual and social settings that serve as distractions, such as going to a local coffee shop or bookstore.
    • Social-support strategies: As third-level strategies, the coordinator and patient develop a list of individuals in the local environment who can provide help in coping with the suicidal crisis, including friends and family members. The plan lists emergency contact numbers for each person who serves as part of the individual’s support network.
    • Professional-support strategies: As a fourth level of support, the plan lists relevant contact information for mental health professionals and agencies available to help the individual, including VA and community-based resources. The plan also reminds the individual to immediately call 911 or come to the ED if the situation becomes urgent.
    • Means restriction: As a final step, the plan identifies ways to restrict access to the means by which an individual might carry out suicide, such as through use of drugs or a weapon.
  • Facilitating engagement in accessing outpatient support: During the ED-based meeting, the coordinator emphasizes the importance of accessing followup outpatient services and works to identify and address any barriers to doing so. For example, the coordinator will make individuals who have no means of traveling to an appointment aware of available transportation services in the area, including but not limited to VA services. In some cases, the coordinator will attempt to arrange for an appointment before the individual leaves the ED.
  • Followup calls to veterans: The coordinator follows up with patients by telephone within 72 hours of the ED visit and then on a weekly basis thereafter until the person becomes engaged in his or her ongoing care. During these calls, the coordinator assesses the individual’s mood and suicide risk; ensures he or she does not need immediate care; reviews the safety plan to ensure it is being used; makes any necessary modifications to the plan; and discusses and seeks to resolve any obstacles to ongoing engagement in care, such as helping reschedule a missed appointment or access transportation services. During the initial demonstration project, the typical patient received just over six followup calls from the coordinator.6

Context of the Innovation

The VA provides patient care and Federal benefits to veterans and their dependents. The organization operates the nation's largest integrated health care system, with more than 1,700 hospitals, clinics, community living centers, readjustment counseling centers, and other facilities. The VA also administers a variety of benefits and services that provide financial and other forms of assistance to active-duty service members, veterans, and their dependents and survivors.

The VA has long made reducing suicides among veterans and the associated burden of such suicides on individuals and family members a top priority. In May 2008, the Secretary of the VA convened the Blue Ribbon Panel on Veteran Suicide to provide guidance on the development of suicide prevention programs within the organization. The group was made up of high-level Federal employees from outside the VA with expertise in public mental health programs (including suicide prevention and education), research (including mental health epidemiology and suicidology), and clinical treatment programs for patients at risk for suicide. Guided by the input of expert consultants, the panel recommended that the VA explore ways to better identify and assist suicidal veterans.9 Recognizing that many suicidal individuals present to the ED and that standard practice in most EDs is to assess and then admit or refer at-risk patients, VA leaders called for development and implementation of an ED-based intervention for suicidal veterans. The goal was to go beyond the referral-only model to provide brief but meaningful support to at-risk veterans in the ED and then follow up with them to ensure they receive appropriate, timely care and support in the community.

Did It Work?

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Results

The intervention has enhanced access to outpatient mental health services for veterans at risk of suicide and has generated positive feedback on acceptability and effectiveness from patients and ED-based clinicians. Ongoing research is more rigorously analyzing the program’s impact on key metrics, including suicide attempts.
  • Enhanced access to outpatient mental health care: During the first 6 months after the initial ED visit, program participants had an average of 9.2 outpatient mental health visits, well above the 4.9 average visits during the same period before the visit. Overall, 69 percent of participants received at least 1 psychiatric service within 2 weeks of the initial ED visit, whereas 80 percent attended 1 or more outpatient mental health followup visits within 6 months of the ED visit. These figures are well above the 10 to 40 percent of patients in the general population who return for a followup mental health visit after being discharged from the ED.4
  • Positive feedback from patients and clinicians: Interviews with 100 patients found generally high levels of satisfaction with program services. Virtually all patients remembered having a safety plan and roughly two-thirds reported using it, with most relying primarily on the internal coping strategies. Those not using the plan still found benefit in knowing that they had one available to them. Patients also expressed high levels of satisfaction with the followup telephone calls, which for many patients served as a signal that the VA “cares about” them. For their part, ED-based clinicians have reacted positively to the program, despite some initial challenges and concerns related to implementing it in a busy, crowded setting.
  • More rigorous, comprehensive evaluation to come: Project developers secured Department of Defense funding to assess the impact of SAFE VET using a more rigorous, quasi-experimental design to evaluate its impact on key outcomes, including the proportion of patients who attempt suicide within 6 months of the initial ED visit, use of suicide-related coping strategies, severity of suicide ideation during the same 6-month period, the proportion of patients who attend more than 1 outpatient mental health or substance abuse treatment appointment within 30 days of the initial ED visit, and the motivation to attend treatment during the 6-month period after the visit.6

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of the number of outpatient mental health visits attended by participants during the 6-month period before and after receiving program services. Additional evidence includes post-implementation data on the proportion of participants accessing mental health services within 2 weeks and 6 months of their initial ED visit, along with feedback from patients and clinicians on their satisfaction with the program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Forming an executive committee: An executive committee formed that was charged with developing the program, overseeing its implementation, evaluating its impact, and disseminating findings. Made up of a small group of researchers and clinicians with expertise in mental health and suicide prevention, this committee worked intensely over a period of several months to get the program up and running, and continues to meet on a regular basis.
  • Adapting existing model for use in ED: Part of the committee’s work involved adapting an established clinical approach known as the Safety Planning Intervention that had been developed for the general population and implemented in non-ED VA settings in 2008. Although mental health patients seen elsewhere in the VA system routinely received this intervention, busy ED clinicians were not used to going beyond the traditional assess-and-admit or assess-and-refer approach. Committee members held meetings with ED representatives to figure out how best to incorporate the Safety Planning Intervention into the ED. As part of this collaborative process, the committee and ED representatives also developed the outreach and followup components of the program.7,8
  • Recruiting initial study sites and site leads: The committee decided to implement and evaluate the program at five sites, comparing key metrics before and after implementation. Because suicide had become such a high-profile issue in the VA and the general press, interest in participating was quite high, with roughly 15 ED leaders expressing a desire to be part of the study. Committee members chose five sites, based on geographical considerations and the willingness of an ED-based physician to champion the program at the local level.
  • Hiring and training coordinators: Often in collaboration with the physician lead, the committee recruited and hired an acute services coordinator for each site. In most cases, these coordinators had masters- or doctoral-level training in behavioral health. The coordinators went through several group training sessions in which they reviewed a comprehensive manual on the program and engaged in role-playing to simulate an ED-based encounter with patients.
  • Planning rollout at each site: The committee worked with the physician leads and acute services coordinators to plan and execute implementation at the local sites.

Resources Used and Skills Needed

  • Staffing: During the initial evaluation, each participating ED had one full-time acute services coordinator who generally worked day and some evening hours (but not weekends). Outside of the research environment, program leaders envision the potential for existing ED-based staff (such as social workers or case managers) to fit some or all program-related activities into their regular job responsibilities, thus reducing and perhaps eliminating the need to hire additional personnel.
  • Costs: Program-related costs consist primarily of the salary and benefits for any incremental staff hired to serve as acute service coordinators.
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Funding Sources

U.S. Department of Defense; U.S. Department of Veterans Affairs
The VA’s Office of Mental Health Services supports SAFE VET. The Military Operational Medicine Research Program within the Department of Defense is funding the more comprehensive followup study described earlier.end fs

Tools and Other Resources

Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population: executive summary. Washington (DC): United States Department of Veterans Affairs; 2008 Jun. Available at: http://www.mentalhealth.va.gov/suicide_prevention/Blue_Ribbon_Report-FINAL_June-30-08.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Do not reinvent the wheel: The Safety Planning Intervention is an evidence-based intervention that has been shown to help reduce the risk of suicide. Would-be adopters should consider using this approach as the basis for an ED-based intervention, along with the structured followup calls developed as part of this program.
  • Identify local champions: Successful implementation depends in large part on having someone onsite willing to serve as a champion of the program, convincing other ED-based staff of the value of investing in preventive strategies that can save lives and eliminate the need for repeat ED visits.
  • Train non-physician staff: Non-physician staff within the ED, including social workers and case managers, can be trained to provide program services, including development of the safety plan in the ED and post-discharge telephone outreach and support.

Sustaining This Innovation

  • Use tracking system to assist with followup: Busy ED-based clinicians may need help keeping track of when to follow up with at-risk patients. Other clinical staff outside of the ED likely have to be identified to provide followup care and support.
  • Monitor and report on program impact: Senior executives and ED-based clinicians will remain supportive of and engaged in the program if they periodically see evidence that it saves lives or prevents future ED visits and hospitalizations.
  • Approach payers about reimbursing for services or sharing savings: Private insurers stand to reap significant financial rewards if this program leads to fewer repeat ED visits or hospitalizations. Consequently, program leaders should share data with payers demonstrating the program's ability to achieve these goals and encourage them to pay for program services or share in the savings generated. Although most payers currently pay a single bundled charge for ED visits, it might be possible to negotiate additional payments for ED-based safety planning or followup telephone support.

Use By Other Organizations

Some other EDs have adopted the Safety Planning Intervention component of this program, but few have combined it with the post-discharge outreach and support.

More Information

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Contact the Innovator

Kerry Knox, PhD
VISN 2 Center of Excellence for Suicide Prevention
Canandaigua VA Medical Center
400 Fort Hill Avenue
Canandaigua, NY 14472
(585) 393-7690
E-mail: kerry.knox@va.gov

Innovator Disclosures

Dr. Knox reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Knox KL, Stanley B, Currier GW, et al. An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET). Am J Public Health. 2012;102(S1):S33-7. [PubMed]

Footnotes

1 Kurz A, Möller HJ. Help-seeking behavior and compliance of suicidal patients. Psychiatr Prax. 1984;11(1):6-13. [PubMed]
2 Taylor EA, Stansfeld SA. Children who poison themselves. I. A clinical comparison with psychiatric controls. Br J Psychiatry. 1984;145:127-32. [PubMed]
3 McCarthy JF, Valenstein M, Kim HM, et al. Suicide mortality among patients receiving care in the veterans health administration health system. Am J Epidemiol. 2009;169(8):1033-38. [PubMed]
4 Boyer CA, McAlpine DD, Pottick KJ, et al. Identifying risk factors and key strategies in linkage to outpatient psychiatric care. Am J Psychiatry. 2000;157(10):1592-98. [PubMed]
5 Van Heeringen C, Jannes S, Buylaert W, et al. The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study. Psychol Med. 1995;25(5):963-70. [PubMed]
6 Knox KL, Stanley B, Currier GW, et al. An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET). Am J Public Health. 2012;102(S1):S33-7. [PubMed]
7 Stanley B, Brown GK, Karlin B, et al. The safety plan treatment manual to reduce suicide risk: veteran version. Washington (DC): United States Department of Veterans Affairs; 2008 Aug. Available at: http://www.mentalhealth.va.gov/docs/VA_Safety_planning_manual.pdf.
8 Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cognit Behav Pract. 2012;19:256-64. Available at: http://www.sciencedirect.com/science/article/pii/S1077722911000630.
9 Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population: executive summary. Washington (DC): United States Department of Veterans Affairs; 2008 Jun. Available at: http://www.mentalhealth.va.gov/suicide_prevention/Blue_Ribbon_Report-FINAL_June-30-08.pdf.
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Original publication: November 20, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.