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.

Extreme Risk Protection Orders: Legislative Intent and Clinician Guidance.

In this second column of a 2-part series exploring extreme risk protections orders, we utilize recent events in Colorado, including legislative efforts to expand the list of eligible petitioners to include clinicians, as an opportunity to explore questions and challenges faced by mental health and medical professionals serving in this capacity. Clinicians are in need of more clear guidance, given an emerging role that comes without clear evidence or practice standards to inform individualized clinical decision-making, and which potentially pits public safety interests against patient care needs, especially those pertaining to therapeutic relationships. In the interim, clinicians will best serve their patients by continuing to practice in a fashion that is analogous to decision-making around other interventions with serious implications for patient autonomy such as involuntary hospitalization. Ongoing collaboration with legislators is needed to arrive at laws that are informed by the limitations inherent in clinical risk assessment and that can be translated into clinical practices that simultaneously support patient needs and community safety.

Lithium Use for Suicide Prevention, Revisited.

The literature on lithium's role in suicide prevention is rife with competing interpretations and diverging opinions, in part stemming from the complexity of the underlying literature base. Conclusions that lithium unequivocally offers suicide prevention benefits do not appear warranted based on the strength of existing studies. Given the evidence along with the indisputable risks associated with lithium (especially in overdose), and the need for sustained therapeutic dosing to achieve any theoretical antisuicide benefit, it seems evident that any potential role for lithium in suicide prevention is far narrower than originally hypothesized. As such, the goal of this article is to provide an evidence-informed, therapeutic risk management approach to clinical decision-making concerning the use of lithium for suicide prevention to ensure that such prescribing is done in a patient-centered fashion that mitigates, to the extent possible, the potential risks of lithium use. This includes a review of potential justifications for not employing lithium for suicide prevention, given the recommendations in the existing guidelines. Clinicians should approach this clinical decision in an individualized fashion with full consideration of the potential risks associated with lithium use and availability, as well as potential alternative treatment options. An individualized risk/benefit analysis must also take into consideration the presence of comorbid conditions; the acuity of suicide risk, and any history of self-directed violence, with special attention to suicide attempts via overdose; treatment adherence, past and present; the presence and/or strength of a therapeutic relationship; and other viable treatment options.

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.

Firearm Injury Prevention and Extreme Risk Protection Orders.

Extreme risk protection orders (ERPOs) represent a potential mechanism to facilitate firearm-related lethal means safety. ERPOs are a legal mechanism that enables law enforcement to temporarily remove firearms from, and prevent firearm purchase by, an individual who presents a significant danger to self or others, as determined by a court of law. While few jurisdictions currently allow mental health professionals to initiate ERPO petitions, it nonetheless seems important that clinicians be familiar with ERPOs, as clinicians may still serve an important role in disseminating information and facilitating judicious petitions. However, ERPO laws remain quite new, and the implications for mental health professionals when participating (directly or indirectly) in ERPOs remain unclear. This column introduces readers to ERPOs and offers resources to learn more about how ERPOs work across various jurisdictions.

Mental health follow-up and treatment engagement following suicide risk screening in the Veterans Health Administration.

IMPORTANCE: Understanding the extent to which population-level suicide risk screening facilities follow-up and engagement in mental health treatment is important as engaging at-risk individuals in treatment is critical to reducing suicidal behaviors. OBJECTIVE: To evaluate mental health follow-up and treatment engagement in the Veterans Health Administration (VHA) following administration of the Columbia-Suicide Severity Rating Scale (C-SSRS) screen, a component of the VHA's universal suicide risk screening program. DESIGN: This cross-sectional study used data from VA's Corporate Data Warehouse. SETTINGS: 140 VHA Medical Centers. PARTICIPANTS: Patients who completed the C-SSRS screen in ambulatory care between October 1, 2018-September 30, 2020. EXPOSURE: Standardized suicide risk screening. MAIN OUTCOMES AND MEASURES: Mental health follow-up (one or more visits within 30 days of C-SSRS screening) and treatment engagement (two or more visits within 90 days of C-SSRS screening) were examined. RESULTS: 97,224 Veterans in Fiscal Year 2019 (FY19) (mean age 51.4 years; 86.8% male; 64.8% white, 22.4% African-American) and 58,693 Veterans in FY20 (mean age 49.6 years; 85.5% male; 63.4% white, 21.9% African-American) received the C-SSRS screen. Across FYs, a positive C-SSRS screen was associated with increased probability of mental health follow-up and treatment engagement. Patients who were not seen in mental health in the year prior to screening had the greatest increase in probability of mental health follow-up and engagement following a positive screen (P<0.001). For FY19, a positive C-SSRS screen in non-mental health connected patients was associated with an increased probability of follow-up from 49.8% to 79.5% (relative risk = 1.60) and engagement from 39.5% to 63.6% (relative risk = 1.61). For mental health-connected patients, a positive C-SSRS screen was associated with a smaller increase in probability of follow-up from 75.8% to 87.6% (relative risk = 1.16) and engagement from 63.3% to 76.4% (relative risk = 1.21). Results for FY20 were similar. CONCLUSIONS AND RELEVANCE: Identification of suicide risk through population-level screening was associated with increased mental health follow-up and engagement, particularly for non-mental health connected patients. Findings support the use of a standardized, comprehensive suicide risk screening program for managing elevated suicide risk in a large healthcare system.

Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study.

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

Therapeutic Risk Management and Firearm-related Lethal Means Safety.

Safety planning to reduce suicide or other-directed violence risk involves efforts toward "making the environment safe," including working collaboratively with at-risk patients to encourage voluntary changes in their firearm storage decisions [ie, lethal means safety (LMS) counseling]. This column provides a conceptual framework and real-world evidence to support the delivery of LMS counseling to at-risk patients, as well as guidance on asking about firearm access and making individualized safety recommendations. It also reviews important elements related to documenting LMS discussions and legal considerations related to these conversations.

Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment Suicide Risk Modeling Clinical Program in the Veterans Health Administration.

Importance: The Veterans Health Administration (VHA) implemented a national clinical program using a suicide risk prediction algorithm, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), in which clinicians facilitate care enhancements for individuals identified in local top 0.1% suicide risk tiers. Evaluation studies are needed. Objective: To determine associations with treatment engagement, health care utilization, suicide attempts, safety plan documentation, and 6-month mortality. Design, Setting, and Participants: This cohort study used triple differences analyses comparing 6-month changes in outcomes after vs before program entry for individuals entering the REACH VET program (March 2017-December 2018) vs a similarly identified top 0.1% suicide risk tier cohort from prior to program initiation (March 2014-December 2015), adjusting for trends across subthreshold cohorts. Subcohort analyses (including individuals from March 2017-June 2018) evaluated difference-in-differences for cause-specific mortality using death certificate data. The subthreshold cohorts included individuals in the top 0.3% to 0.1% suicide risk tier, below the threshold for REACH VET eligibility, from the concurrent REACH VET period and from the pre-REACH VET period. Data were analyzed from December 2019 through September 2021. Exposures: REACH VET-designated clinicians treatment reevaluation and outreach for care enhancements, including safety planning, increased monitoring, and interventions to enhance coping. Main Outcomes and Measures: Process outcomes included VHA scheduled, completed, and missed appointments; mental health visits; and safety plan documentation and documentation within 6 months for individuals without plans within the prior 2 years. Clinical outcomes included mental health admissions, emergency department visits, nonfatal suicide attempts, and all-cause, suicide, and nonsuicide external-cause mortality. Results: A total of 173 313 individuals (mean [SD] age, 51.0 [14.7] years; 161 264 [93.1%] men and 12 049 [7.0%] women) were included in analyses, including 40 816 individuals eligible for REACH VET care and 36 604 individuals from the pre-REACH VET period in the top 0.1% of suicide risk. The REACH VET intervention was associated with significant increases in completed outpatient appointments (adjusted triple difference [ATD], 0.31; 95% CI, 0.06 to 0.55) and proportion of individuals with new safety plans (ATD, 0.08; 95% CI, 0.06 to 0.10) and reductions in mental health admissions (ATD, -0.08; 95% CI, -0.10 to -0.05), emergency department visits (ADT, -0.03; 95% CI, -0.06 to -0.01), and suicide attempts (ADT, -0.05; 95% CI, -0.06 to -0.03). Subcohort analyses did not identify differences in suicide or all-cause mortality (eg, age-and-sex-adjusted difference-in-difference for suicide mortality, 0.0007; 95% CI, -0.0006 to 0.0019). Conclusions and Relevance: These findings suggest that REACH VET implementation was associated with greater treatment engagement and new safety plan documentation and fewer mental health admissions, emergency department visits, and suicide attempts. Clinical programs using risk modeling may be effective tools to support care enhancements and risk reduction.

Therapeutic Risk Management for Violence: Safety Planning for Other-directed Violence.

Therapeutic management of risk for other-directed violence (ODV) involves screening, assessment, and clinically appropriate intervention. In this 5-part series, effective screening and assessment for ODV have been described as a combination of clinical interviewing and the use of structured tools to inform clinical impressions of both acute and chronic risk for violence. Once risk of violence is identified, therapeutic management of the risk throughout the course of treatment is best achieved by determining the function of the violent ideation and behavior. This can be achieved through the use of functional chain analysis. Chain analysis not only serves the purpose of providing insight into the contingencies of violent behavior but also helps to identify target areas of intervention where other skills, strategies, and means to access resources for support can be applied. In this fifth and final column of the series, we describe an intervention with all of these outcomes as its goals. A safety plan for ODV assists both clients and mental health professionals in disrupting patterns of violent ideation or behavior that would otherwise continue causing not only harm to others but prolonged negative consequences for those engaging in such behaviors.

Therapeutic Risk Management for Violence: Chain Analysis of Other-directed Violent Ideation and Behavior.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence (ODV) risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of ODV ideation and behavior; and a personalized safety plan to mitigate/manage risk. In this fourth column of the series, we describe chain analysis as a critical tool for assessing and intervening on ODV ideation and behavior. We identify the pathways of reinforcement that can cause ODV to persist, and how to navigate potential barriers to completing ODV chains. Using a case example, we demonstrate how to apply chain analysis to ODV ideation and behavior and offer interventional strategies that can be used to disrupt the chain and ultimately reduce the risk for violence.

Reconciling Statistical and Clinicians' Predictions of Suicide Risk.

Statistical models, including those based on electronic health records, can accurately identify patients at high risk for a suicide attempt or death, leading to implementation of risk prediction models for population-based suicide prevention in health systems. However, some have questioned whether statistical predictions can really inform clinical decisions. Appropriately reconciling statistical algorithms with traditional clinician assessment depends on whether predictions from these two methods are competing, complementary, or merely duplicative. In June 2019, the National Institute of Mental Health convened a meeting, "Identifying Research Priorities for Risk Algorithms Applications in Healthcare Settings to Improve Suicide Prevention." Here, participants of this meeting summarize key issues regarding the potential clinical application of suicide prediction models. The authors attempt to clarify the key conceptual and technical differences between traditional risk prediction by clinicians and predictions from statistical models, review the limited evidence regarding both the accuracy of and the concordance between these alternative methods of prediction, present a conceptual framework for understanding agreement and disagreement between statistical and clinician predictions, identify priorities for improving data regarding suicide risk, and propose priority questions for future research. Future suicide risk assessment will likely combine statistical prediction with traditional clinician assessment, but research is needed to determine the optimal combination of these two methods.

Feasibility and Acceptability of the HOME Program for Veterans Recently Discharged from a Psychiatric Hospitalization.

Enrollment in the Home-Based Mental Health Evaluation (HOME) Program is associated with higher rates of treatment engagement following psychiatric hospitalization discharge, as compared to enhanced care as usual. We aim to describe feasibility and acceptability data related to implementation of the HOME Program at two Department of Veterans Affairs Medical Centers (VAMCs) to inform future program refinement and implementation. Process evaluation data regarding feasibility and acceptability were collected in the context of an interventional multi-site trial. Data regarding enrollment in the study and the intervention were collected by study staff. Additional acceptability and feasibility data were obtained via the Client Satisfaction Questionnaire-8 (CSQ-8) and Narrative Evaluation of Intervention Interview (NEII). Between 82 and 91% of enrolled Veterans participated in at least one post-discharge telephone contact. Site differences existed with respect to completion of home visits. CSQ-8 results suggested high levels of satisfaction with the HOME Program. Themes identified via the NEII reflect that as a result of participation in the HOME Program, Veterans felt hopeful and cared for and learned how to keep themselves safe following hospital discharge. Process evaluation data from a clinical trial of the HOME Program demonstrated that the intervention was feasible to implement at two VAMCs and was acceptable to participants. These data inform considerations for future research and implementation efforts.Trial Registration ClinicalTrials.gov Identifier: NCT03347552.

Therapeutic Risk Management for Violence: Stratifying Risk and Characterizing Violence.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and personalized safety plans to mitigate/manage risk. This third column in the series describes other-directed violence risk stratification in terms of both severity and temporality, as well an approach for characterizing (ie, predatory/planned or impulsive/reactive) the violence risk posed by an individual.

Assessment of Rates of Suicide Risk Screening and Prevalence of Positive Screening Results Among US Veterans After Implementation of the Veterans Affairs Suicide Risk Identification Strategy.

Importance: In 2018, the Veterans Health Administration (VHA) implemented the Veterans Affairs (VA) Suicide Risk Identification Strategy to improve the identification and management of suicide risk among veterans receiving VHA care. Objectives: To examine the prevalence of positive suicide screening results among veterans in ambulatory care and emergency departments (EDs) or urgent care clinics (UCCs) and to compare acuity of suicide risk among patients screened in these settings. Design, Setting, and Participants: This cross-sectional study used data from the VA's Corporate Data Warehouse (CDW) to assess veterans with at least 1 ambulatory care visit (n = 4 101 685) or ED or UCC visit (n = 1 044 056) at 140 VHA medical centers from October 1, 2018, through September 30, 2019. Exposures: Standardized suicide risk screening and evaluation tools. Main Outcomes and Measures: One-year rate of suicide risk screening and evaluation, prevalence of positive primary and secondary suicide risk screening results, and levels of acute and chronic risk based on the VHA's Comprehensive Suicide Risk Evaluation. Results: A total of 4 101 685 veterans in ambulatory care settings (mean [SD] age, 62.3 [16.4] years; 3 771 379 [91.9%] male; 2 996 974 [73.1%] White) and 1 044 056 veterans in ED or UCC settings (mean [SD] age, 59.2 [16.2] years; 932 319 [89.3%] male; 688 559 [66.0%] White) received the primary suicide screening. The prevalence of positive suicide screening results was 3.5% for primary screening and 0.4% for secondary screening in ambulatory care and 3.6% for primary screening and 2.1% in secondary screening for ED and UCC settings. Compared with veterans screened in ambulatory care, those screened in the ED or UCC were more likely to endorse suicidal ideation with intent (odds ratio [OR], 4.55; 95% CI, 4.37-4.74; P < .001), specific plan (OR, 3.16; 95% CI, 3.04-3.29; P < .001), and recent suicidal behavior (OR, 1.95; 95% CI, 1.87-2.03; P < .001) during secondary screening. Among the patients who received a Comprehensive Suicide Risk Evaluation, those in ED or UCC settings were more likely than those in ambulatory care settings to be at high acute risk (34.1% vs 8.5%; P < .001). Conclusions and Relevance: In this cross-sectional study, population-based suicide risk screening and evaluation in VHA ambulatory care and ED or UCC settings may help identify risk among patients who may not be receiving mental health treatment. Higher acuity of risk among veterans in ED or UCC settings compared with those in ambulatory care settings highlights the importance of scaling up implementation of brief evidence-based interventions in the ED or UCC to reduce suicidal behavior.

Therapeutic Risk Management for Violence: Augmenting Clinical Risk Assessment With Structured Instruments.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and a personalized safety plan to mitigate/manage risk. This second column in the series describes the advantages of, and offers suggestions for, incorporating structured tools into violence risk assessment.

Protocol: examining the effectiveness of an adaptive implementation intervention to improve uptake of the VA suicide risk identification strategy: a sequential multiple assignment randomized trial.

BACKGROUND: In 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk ID). The goal of Risk ID is to improve the detection and management of suicide risk by standardizing suicide risk screening and evaluation enterprise-wide. In order to ensure continuous quality improvement (QI), ongoing evaluation and targeted interventions to improve implementation of Risk ID are needed. Moreover, given that facilities will vary with respect to implementation needs and barriers, the dose and type of intervention needed may vary across facilities. Thus, the objective of this study is to examine the effectiveness of an adaptive implementation strategy to improve the uptake of suicide risk screening and evaluation in VHA ambulatory care settings. In addition, this study will examine specific factors that may impact the uptake of suicide risk screening and evaluation and the adoption of different implementation strategies. This protocol describes the stepped implementation approach and proposed evaluation plan. METHODS: Using a sequential multiple assignment randomized trial (SMART) design, two evidence-based implementation strategies will be evaluated: (1) audit and feedback (A&F); (2) A&F plus external facilitation (A&F + EF). Implementation outcomes of interest include uptake of secondary suicide risk screening and uptake of comprehensive suicide risk evaluation (stages 2 and 3 of Risk ID). Secondary outcomes include rates of other clinical outcomes (i.e., safety planning) and organizational factors that may impact Risk ID implementation (i.e., leadership climate and leadership support). DISCUSSION: This national QI study will use a SMART design to evaluate whether an adaptive implementation strategy is effective in improving uptake of a mandated VHA-wide suicide risk screening and evaluation initiative. If this study finds that the proposed stepped implementation strategy is effective at increasing uptake and maintaining performance improvements, this approach may be used as an overarching QI strategy for other national suicide prevention programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04243330 . Registered 28 January 2020.

Therapeutic Risk Management for Violence: Clinical Risk Assessment.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting (and documenting) screening, assessment, and management of other-directed violence risk. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving a clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and development of a personalized safety plan. This first column of the series focuses on essential aspects of the clinical interview.