Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities.

INTRODUCTION: Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare. METHODS: This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices. RESULTS: Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided. DISCUSSION: Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Characteristics and Context of Veterans Experiencing Serious Suicidal Ideation or Suicide Attempt by Firearm which led to Hospitalization.

OBJECTIVE: Suicide by former United States military service members is of great public health concern, and one area, veterans' suicide attempts involving firearms, is understudied. One group that has a unique perspective on this are veterans with a psychiatric admission following a firearm-related suicide crisis, such as making a suicide plan or a suicide rehearsal with a firearm within the preceding 72 hours. This study seeks to address this gap in the literature by describing the characteristics and context of non-fatal suicide events involving firearms among veterans. METHOD: This convergent parallel mixed-methods design study collected both quantitative and qualitative data from male veterans (N = 15) who were hospitalized due to a suicide attempt or serious ideation using a firearm. Veterans admitted to a Veterans Affairs Medical Center (VAMC) were interviewed and asked to complete a survey. Qualitative data on characteristics and context were analyzed using a thematic analysis. RESULTS: The fifteen male U.S. military veterans described their personal characteristics, such as their beliefs, family beliefs and structure, emotions, and employment status. Most participants were unemployed (n = 10; 67%), divorced (n = 7; 47%) or married (n = 5; 33%). Seven themes related to context emerged from qualitative interviews to include: combat trauma, non-combat trauma and negative life event(s), current and past suicide attempt(s), firearms, substance use, known deaths by suicide, and protective factors for suicide. CONCLUSION: Results suggest that engaging support networks and communities is essential when developing programs to promote identification of early warning signs and implementation of interventions or programs for reducing veteran suicide.

Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial.

Objective: The emergency department (ED) is an important site for suicide prevention efforts, and safety planning has been identified as a best practice for suicide prevention among ED patients at increased suicide risk. However, few ED clinicians are prepared to assess suicide risk or guide patients in the creation of safety plans. This study was a pilot randomized controlled trial of the feasibility, acceptability, and preliminary effects of safety planning by individuals with lived experience of suicide attempt or of severe suicidal ideation but without medical training (i.e., peers) in the ED. Methods: Patients at risk for suicide in a general ED were randomly assigned to receive peer-delivered or mental health provider­delivered safety planning. Intervention feasibility measures included ED length of stay, safety plan completeness, and safety plan quality. Acceptability measures included patient satisfaction. Preliminary effects were assessed as number of ED returns within the 3 months after the ED visit. Results: Data from 31 participants were available for analysis. Compared with participants with provider-delivered safety planning, participants with peer-delivered safety planning had similar ED lengths of stay, higher safety plan completeness, and higher safety plan quality. Acceptability of the safety planning process was similar for the two groups. Compared with participants receiving provider-delivered safety planning, participants receiving peer-delivered planning had significantly fewer ED visits during the subsequent 3 months than during the 3 months preceding the ED visit. Conclusions: Peer-delivered safety planning is feasible and acceptable and may result in fewer return ED visits. These findings provide preliminary support for peer-delivered safety planning in the ED.

Formative evaluation of Zero Suicide in the emergency department: Identifying strategies to overcome implementation barriers.

BACKGROUND: Zero Suicide has been widely promoted as a comprehensive suicide prevention approach in healthcare systems, yet less is known about the barriers to implementing this approach in the emergency department. OBJECTIVES: This developmental evaluation aimed to assess emergency department providers' perceived knowledge and self-efficacy regarding suicide prevention practices, as well as apply the Consolidated Framework for Implementation Research to explore potential facilitators and barriers to implementing Zero Suicide and identify strategies to overcome barriers. METHODS: A sequential mixed methods approach was used, including a survey assessing emergency department providers' perceived knowledge and attitudes and semi-structured interviews exploring potential determinants of implementation. RESULTS: Survey respondents (n = 43) perceived that they have the knowledge and self-efficacy to implement clinical elements of Zero Suicide; however, interview participants (n = 18) revealed that some clinical elements are not implemented consistently and perceive implementation barriers across multiple levels, including limited training on suicide risk assessment and limited resources needed to engage and re-engage at-risk patients in their suicide care management plan and provide follow-up supportive contacts during patients' transitions in care. CONCLUSION: To overcome identified barriers in this setting, targeted implementation strategies are needed, including integration in electronic health record systems, leadership advocacy, and ongoing staff training.

Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation.

BACKGROUND: Traditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can "go to scale." However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes. METHODS/DESIGN: In this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread. DISCUSSION: As an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.

Using Community Advisory Boards to Build Partnerships and Develop Peer-Led Services for Rural Student Veterans.

BACKGROUND: The Department of Veterans' Affairs (VA)/Student Partnership for Rural Veterans (VSP) built partnerships between institutional (health services researchers, VA chaplains) and community groups to develop veteran-to-veteran services on college campuses. OBJECTIVES: Describe challenges and lessons learned in year 1 of the VSP project at six campuses in rural Arkansas. METHODS: Researchers leveraged established community advisory boards (CABs) to develop veteran-to-veteran services. Ethnographic and qualitative methods were used to assess partnership building and evaluate peer-led services. RESULTS: Local established CABs and buy-in from student services and veteran organizations was instrumental to building partnerships and developing services. Challenges included developing rapport with campus leaders and creating sustainable role/expectations for student veteran leaders. CONCLUSIONS: Peer-led services are an ideal way to connect student veterans and link them to resources and health care services. Partnerships can facilitate grassroots efforts to develop local services that meet the needs of diverse student veteran populations.

Psychological traumas of war: training school counselors as home-front responders.

PURPOSE: With nearly 3 million U.S. troops having deployed for Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) since the conflicts began, an estimated 2 million children have been separated from a parent. This manuscript describes a collaborative project between a state's Veterans Healthcare System, a branch of the American Counseling Association, and a medical university on the OEF/OIF/OND deployment experience. METHODS: The project sought to educate school counselors about experiences of OEF/OIF/OND families and learn from their observations as home-front responders in public schools during a 2-day summer workshop. This manuscript describes the framework of the workshop, pre/post evaluation results, and implications for counselors, educators, and supervisors. FINDINGS: School counselors identified childcare and parenting, emotions and behaviors, finances, and barriers to counseling services as challenges for military children and families. Following the workshop, school counselors reported a greater knowledge concerning understanding aspects of outreach for schools and communities in working with veterans and their families. They also reported a better understanding of the impact of war on military families and knowledge of local and state resources for this population. Specifically, attendees felt they could better identify issues and needs of OEF/OIF/OND families with young children, recommend parenting skills to assist these families, and recognize their psychiatric or medical issues. CONCLUSION: In addressing the mental health disparities of military children experiencing combat-related parental separation, it is important to identify protective environments that could provide prevention interventions for this population. Collaboration between the Department of Defense, Department of Veterans Affairs (VA), and Department of Education could help support military families and a society facing continued conflicts abroad.