Qualitative Evaluation of a Caring Letters Suicide Prevention Intervention for the Veterans Crisis Line.

OBJECTIVE: Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters. METHODS: Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention. RESULTS: Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care. CONCLUSIONS: The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes.

Development of the Veterans Crisis Line Caring Letters Suicide Prevention Intervention.

OBJECTIVE: To describe the design, implementation, and plans to evaluate the Veterans Crisis Line (VCL) Caring Letters intervention. DATA SOURCES: Veterans with VCL contact and VHA service utilization. STUDY DESIGN: Caring Letters is an evidence-based post-acute care suicide prevention intervention in which brief messages are mailed to individuals at high risk of suicide repeatedly over time to communicate that people care about them and are concerned for their well-being. An effectiveness-implementation hybrid type 1 trial using the RE-AIM evaluation framework is underway to examine the use of Caring Letters with veterans who contact the VCL. A team of suicide prevention subject matter experts, researchers, and operational partners from the VCL will evaluate the effects of Caring Letters on clinical outcomes and Department of Veterans Affairs - Veterans Health Administration (VHA) clinical utilization rates and examine facilitators and barriers to implementing the Caring Letters campaign. DATA COLLECTION METHODS: Veterans who contact the VCL are linked with national administrative VHA data. Semi-structured interviews were conducted as part of a qualitative formative evaluation. PRINCIPAL FINDINGS: In the first 12 months of the intervention, Caring Letters have been sent to over 100,000 veterans with VCL contact (over 500,000 letters mailed). A formative qualitative evaluation early in implementation revealed a variety of positive veteran perspectives on the intervention. CONCLUSIONS: Partnered program design and evaluation with a high level of stakeholder engagement and participant feedback can result in a rigorous and feasible evaluation plan that improves implementation processes and produces actionable results. The initial results of this evaluation will be used to better inform care in the VHA and, specifically, the VCL.

Implementation strategy to increase clinicians' use of the caring letters suicide prevention intervention.

Caring Letters is recommended in multiple best practice guidelines; however, the Caring Letters intervention has not been widely implemented. The process of tracking, scheduling, and mailing letters for multiple patients over many months may represent a significant barrier for busy clinicians. This evaluation examined whether the use of centralized administrative support (Centralized Caring Letters; CCL) was associated with increased utilization of the intervention. These procedures were tested in the Department of Veterans Affairs (VA) Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program. In REACH VET, VA clinicians are routinely asked to consider Caring Letters as one option for veterans identified as at-risk. In this evaluation, clinicians at two VA facilities were offered assistance in the tracking, preparation, mailing, and documentation of Caring Letters for veterans they chose to enroll in CCL. The utilization of Caring Letters increased more than 14-fold after CCL was implemented. In the year that preceded CCL, 3% of REACH VET veterans were sent Caring Letters at the two sites; this increased to 43% of cases after the implementation of CCL (45% at Site 1 and 41% at Site 2). In qualitative interviews with providers, clinicians described Caring Letters as beneficial and stated that the centralized features of the program were helpful. Caring Letters were discontinued for 30% of enrolled veterans, often because of a bad address (9% of enrolled) or relocation (8% of enrolled). Although there are barriers for the use of Caring Letters, CCL was associated with a very large increase in the use of Caring Letters. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.