Ascertainment of Patient Suicides by Veterans Affairs Facilities and Associations With Veteran, Clinical, and Suicide Characteristics.

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics. Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics. Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods. Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention.

Brief Report: Opioid-Involved Overdose Mortality in United States Veterans.

BACKGROUND AND OBJECTIVES: The purpose of this study is to assess trends in opioid-involved overdose mortality among US Veterans. METHODS: Age-adjusted drug overdose mortality rates, overall and by opioid subtype, were assessed from National Death Index data for US Veterans; statistical significance of trends was assessed for 2010 to 2015 and 2015 to 2016. RESULTS: Veteran age-adjusted overdose mortality rates increased 23.7% from 2010 to 2015 (19.7-24.4 of 100 000) and a further 20.4% through 2016 (29.3 of 100 000). Opioid involvement increased from 51.3% in 2010 to 62.1% in 2016, as opioid overdose rates increased from 10.9 to 19.5 of 100 000. Overdose mortality varied substantially by opioid subtype and demographics. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This report provides the first-ever description of trends and characteristics of overdose mortality and opioid-involved deaths among US Veterans of military service for the period 2010 to 2016. With the exception of female Veterans and Veterans in Western States, it has been found that trends in Veteran overdose mortality paralleled rising rates of drug overdose observed in the United States more broadly. Published 2020. This article is a U.S. Government work and is in the public domain in the USA. (Am J Addict 2020;00:00-00).

Treatment satisfaction with ITCA 650, a novel drug-device delivering continuous exenatide, versus twice-daily injections of exenatide in type 2 diabetics using metformin.

AIMS: To evaluate treatment satisfaction in patients with type 2 diabetes (T2D) not adequately controlled by metformin, randomized to ITCA 650 (continuous exenatide in osmotic mini-pump) vs twice-daily exenatide injections (Ex-BID). MATERIALS AND METHODS: The Diabetes Medication Satisfaction Tool (DM-SAT) was administered and assessments were made at baseline, Week 8 and Week 20 during a 24-week open-label phase 2 trial. In Stage I (Weeks 1-12), 155 patients, comprising the ITT population, were randomized to 3 groups: ITCA 650 20 µg/day, ITCA 650 40 µg/day and Ex-BID 10 µg BID. In Stage II (Weeks 13-24), ITCA 650 groups were re-randomized to either remain on the Stage I dose or receive a higher dose. Patients treated with Ex-BID were randomized to 40 or 60 µg/day ITCA 650. RESULTS: Patients using ITCA 650 reported significant increases in overall treatment satisfaction by Week 8 vs those using Ex-BID (P < .01), despite similar clinical efficacy and overall rates of nausea. During Stage II, further improvement in HbA1c and weight were seen after 3-fold dose escalation of ITCA 650 and treatment satisfaction was maintained. When patients using Ex-BID were switched to ITCA 650, treatment satisfaction increased and reached levels similar to those initially treated with ITCA 650. Neither GI side effects of nausea and/or vomiting, nor the procedure to sub-dermally place ITCA 650, significantly impacted treatment satisfaction scores. CONCLUSION: ITCA 650 added to metformin for patients with T2D, and for those who switched to ITCA 650 from Ex-BID, meaningfully improved glucose control and significantly increased overall treatment satisfaction.

Political transition and emergent forest-conservation issues in Myanmar.

Political and economic transitions have had substantial impacts on forest conservation. Where transitions are underway or anticipated, historical precedent and methods for systematically assessing future trends should be used to anticipate likely threats to forest conservation and design appropriate and prescient policy measures to counteract them. Myanmar is transitioning from an authoritarian, centralized state with a highly regulated economy to a more decentralized and economically liberal democracy and is working to end a long-running civil war. With these transitions in mind, we used a horizon-scanning approach to assess the 40 emerging issues most affecting Myanmar's forests, including internal conflict, land-tenure insecurity, large-scale agricultural development, demise of state timber enterprises, shortfalls in government revenue and capacity, and opening of new deforestation frontiers with new roads, mines, and hydroelectric dams. Averting these threats will require, for example, overhauling governance models, building capacity, improving infrastructure- and energy-project planning, and reforming land-tenure and environmental-protection laws. Although challenges to conservation in Myanmar are daunting, the political transition offers an opportunity for conservationists and researchers to help shape a future that enhances Myanmar's social, economic, and environmental potential while learning and applying lessons from other countries. Our approach and results are relevant to other countries undergoing similar transitions.

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.

OBJECTIVES: The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. METHODS: Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. RESULTS: Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. CONCLUSIONS: Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Reducing patients' exposures to asthma and allergy triggers in their homes: an evaluation of effectiveness of grades of forced air ventilation filters.

OBJECTIVE: Many interventions to reduce allergen levels in the home are recommended to asthma and allergy patients. One that is readily available and can be highly effective is the use of high performing filters in forced air ventilation systems. METHODS: We conducted a modeling analysis of the effectiveness of filter-based interventions in the home to reduce airborne asthma and allergy triggers. This work used "each pass removal efficiency" applied to health-relevant size fractions of particles to assess filter performance. We assessed effectiveness for key allergy and asthma triggers based on applicable particle sizes for cat allergen, indoor and outdoor sources of particles <2.5 µm in diameter (PM2.5), and airborne influenza and rhinovirus. RESULTS: Our analysis finds that higher performing filters can have significant impacts on indoor particle pollutant levels. Filters with removal efficiencies of >70% for cat dander particles, fine particulate matter (PM2.5) and respiratory virus can lower concentrations of those asthma triggers and allergens in indoor air of the home by >50%. Very high removal efficiency filters, such as those rated a 16 on the nationally recognized Minimum Efficiency Removal Value (MERV) rating system, tend to be only marginally more effective than MERV12 or 13 rated filters. CONCLUSIONS: The results of this analysis indicate that use of a MERV12 or higher performing air filter in home ventilation systems can effectively reduce indoor levels of these common asthma and allergy triggers. These reductions in airborne allergens in turn may help reduce allergy and asthma symptoms, especially if employed in conjunction with other environmental management measures recommended for allergy and asthma patients.

Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study.

BACKGROUND: Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate. METHODS: A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008. RESULTS: Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015). CONCLUSIONS: In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

Associations of Mortality Outcomes With Employment Status at Discharge From VA Vocational Rehabilitation Service Programs.

OBJECTIVE: The authors evaluated associations between employment at discharge from Veterans Health Administration Vocational Rehabilitation Service (VR) programs and suicide and other causes of death. METHODS: For veterans receiving VR between October 1, 2005, and September 30, 2014 (N=78,293), proportional hazards analyses were used to test associations of employment with suicide, drug overdose, and external and natural cause mortality rates over 1 and 5 years postdischarge and through December 31, 2019. The analyses were adjusted for clinical and sociodemographic characteristics and propensity for employment. RESULTS: Of the veterans, 94.1% had a psychiatric diagnosis, and 35.5% were employed at VR discharge. In proportional hazards analyses, employment was associated with lower mortality rates through 1 year (suicide, hazard ratio [HR]=0.54; overdose, HR=0.70; external causes, HR=0.62; and natural causes, HR=0.51) and 5 years postdischarge (overdose, HR=0.72; external causes, HR=0.81; and natural causes, HR=0.72). Through December 31, 2019, employment was associated with lower risks for overdose (HR=0.80) and death by external (HR=0.81) and natural (HR=0.80) causes. CONCLUSIONS: Employment at VR discharge was associated with lower mortality risk among veterans with psychiatric diagnoses.

Implementing and evaluating a veterans crisis line quality improvement initiative: The safety planning pilot program.

The Veterans Crisis Line (VCL) is part of the U.S. Department of Veterans Affairs' suicide prevention mission. In 2021, VCL assessed the impact of a pilot implementation project of conducting six-part safety plans (SPs) instead of VCL's usual risk mitigation plan. VCL responders offered to complete six-part SPs with eligible callers. Parametric and nonparametric methods compared call characteristics and Veteran Health Administration (VHA) utilization of eligible callers, by SP completion. We forecasted the operational impact of VCL-wide implementation. 27.37% (N = 448/1,637) of calls to designated responders were eligible for SPs. Of those, 27.23% (N = 122/448) completed SPs. Common barriers were call interruptions and the veteran declining. Among veteran callers who use VHA, SP completers were more likely to accept clinical referrals and had more outpatient mental health appointments before and after their VCL call. Calls involving SPs had a call plus documentation time 175% longer than eligible calls without SPs (87.78 vs. 49.66 min). If SPs were implemented VCL-wide, this would require 3-5(4.12%) more responders per hour to maintain current VCL call answer speed. SPs are adaptable to VCL; however, implementation presents logistical barriers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups.

OBJECTIVE: Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS: The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS: PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS: PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide.

OBJECTIVE: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.

Trends and predictors of quality of care in VA nursing homes related to serious mental illness.

OBJECTIVE: Within Veterans Affairs (VA) nursing homes (NHs), quality issues have a tremendous impact on the population with serious mental illness (SMI), who are more likely than their non-SMI Veteran counterparts to use NH services. We examined recent trends in quality indicators (QIs) measuring poor performance of VA NHs and whether the facility-level QIs vary with SMI concentration within the facility. METHODS: From VA administrative records including Minimum Data Set assessments, we identified all residents in the 135 VA NHs between fiscal years 2005 (FY05) through FY07. We used a zero-inflated Poisson regression to assess trends in and facility-level predictors of 3 process-related QIs: depression without antidepressant therapy; bladder/bowel incontinence without a toileting plan; and physical restraint use. Facility-level predictors included collocated special care units, rurality, staffing, physical plant characteristics, SMI prevalence, and SMI admission volume. RESULTS: During FY05-FY07, restraint use declined from 1.2% to 1.1% and incontinence without a toileting plan from 25.8% to 22.1%, but untreated depression increased from 5.1% to 5.5%. Despite overall gains in quality, higher SMI prevalence was associated with higher odds of physical restraint use and lack of toileting plan. Higher SMI prevalence was also associated with higher frequency of untreated depression. Other characteristics such as complex building structure were predictive of variation in quality, but the relationships were not consistent across QI types. CONCLUSION: VA NHs had significant improvements in these examined QIs during the study period. Nonetheless, overall poorer quality was observed at sites with higher SMI concentrations.

Integrated care: treatment initiation following positive depression screens.

BACKGROUND: Primary Care-Mental Health Integration (PC-MHI) may improve mental health services access and continuity of care. OBJECTIVE: To assess whether receipt of integrated PC-MHI services on the date of an initial positive depression screen influences receipt of depression treatment among primary care (PC) patients in the Veterans Health Administration. DESIGN: Retrospective cohort study. SUBJECTS: Thirty-six thousand, two hundred and sixty-three PC patients with positive depression screens between October 1, 2009 and September 30, 2010. MAIN MEASURES: Subjects were assessed for depression diagnosis and initiation of antidepressants or psychotherapy on the screening day, within 12 weeks, and within 6 months. Among individuals with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Using multivariable generalized estimating equations (GEE) logistic regression, we assessed likelihood of treatment initiation, adjusting for demographic and clinical measures, including depression screening score. KEY RESULTS: Patients who received same-day PC-MHI services were more likely to initiate psychotherapy (OR: 8.16; 95 % CI: 6.54-10.17) and antidepressant medications (OR: 2.33, 95 % CI: 2.10-2.58) within 12 weeks than were those who received only PC services on the screening day. CONCLUSIONS: Receipt of same-day PC-MHI may facilitate timely receipt of depression treatment.

Associations between psychiatric inpatient bed supply and the prevalence of serious mental illness in Veterans Affairs nursing homes.

OBJECTIVES: We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA). METHODS: We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings. RESULTS: From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43,894-40,928), the average inpatient length of stay decreased (33.1-19.0 days), and the prevalence of SMI in nursing homes rose (29.4%-43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%). CONCLUSIONS: These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.

Suicide mortality following nursing home discharge in the Department of Veterans Affairs health system.

OBJECTIVES: We assessed suicide rates up to 6 months following discharge from US Department of Veterans Affairs (VA) nursing homes. METHODS: In VA Minimum Data Set (MDS) records, we identified 281 066 live discharges from the 137 VA nursing homes during fiscal years 2002 to 2008. We used MDS and administrative data to assess resident age, gender, behaviors, pain, and indications of psychoses, bipolar disorder, dementia, and depression. We identified vital status and suicide mortality within 6 months of discharge through National Death Index searches. RESULTS: Suicide rates within 6 months of discharge were 88.0 per 100 000 person-years for men and 89.4 overall. Standardized mortality ratios relative to age- and gender-matched individuals in the VA patient population were 2.3 for men (95% confidence interval [CI] = 1.9, 2.8) and 2.4 overall (95% CI = 2.0, 2.9). In multivariable proportional hazards regression analyses, resident characteristics, diagnoses, behaviors, and pain were not significantly associated with suicide risk. CONCLUSIONS: Suicide risk was elevated following nursing home discharge. This underscores the importance of ongoing VA efforts to enhance discharge planning and timely postdischarge follow-up.

Misclassification of suicide deaths: examining the psychiatric history of overdose decedents.

OBJECTIVES: The intent of a death from overdose can be difficult to determine. The goal of this study was to examine the association of psychiatric diagnoses among overdose deaths ruled by a medical examiner as intentional, unintentional and indeterminate intent. METHODS: All Veterans Health Administration patients in Fiscal Year 1999 (n=3 291 891) were followed through Fiscal Year 2006. We tested the relative strength of association between psychiatric disorders among types of overdoses (categorised by intent) using multinomial models, adjusted for age, sex, Veterans Affairs priority status and Charlson comorbidity scores. Data were from National Death Index records and patient medical records. RESULTS: Substance use disorders (SUD) had a stronger association with indeterminate intent overdoses than intentional overdoses (adjusted OR (AOR)=1.80, 95% CI 1.47 to 2.22). SUDs also had a stronger association with unintentional overdoses than intentional (AOR=1.48, 95% CI 1.27 to 1.72), but the reverse was true for all other psychiatric disorders (except post-traumatic stress disorder). CONCLUSIONS: Overdoses ruled indeterminate may be misclassified suicide deaths and are important to suicide surveillance and prevention efforts. Additionally, overdose deaths not classified as suicides may include some cases due to suicidal-like thinking without overt suicidal intent.

Suicide risk following a new cancer diagnosis among Veterans in Veterans Health Administration care.

BACKGROUND: Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk. METHODS: Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012-2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis. RESULTS: A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR] = 1.47, 95% CI: 1.33-1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR = 6.01, 95% CI: 3.73-9.68), and other significant subtypes included head and neck (aHR = 3.55, 95% CI: 2.74-4.62) and lung cancer (aHR = 2.35, 95% CI: 1.85-3.00). Cancer stages 3 (aHR = 2.36, 95% CI: 1.80-3.11) and 4 (aHR = 3.53, 95% CI: 2.81-4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3-6- and 6-12-month periods following diagnosis. CONCLUSION: Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer.

The Veterans Health Administration REACH VET Program: Suicide Predictive Modeling in Practice.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.