What Now?: Experiences of VHA patients following disclosure of suicidal ideation in primary care and mental health settings.

OBJECTIVE: While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings. METHOD: Qualitative thematic analysis using a conventional/directed hybrid approach. RESULTS: A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options. CONCLUSIONS: While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care.

Veteran Perspectives on Population-Based Suicide Risk Screening in VHA Primary Care: Mixed-Methods Study.

BACKGROUND: In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. OBJECTIVE: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. DESIGN: Mixed methods; survey and qualitative interviews. PARTICIPANTS: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. MAIN MEASURES: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. KEY RESULTS: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. CONCLUSIONS: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts.

Primary Care and Mental Health Staff Perspectives on Universal Suicide Risk Screening and Care Coordination.

Little is known about staff or patient perspectives on suicide risk screening programs. The objectives of this study were to characterize Veterans Health Administration (VHA) primary care and mental health staff perspectives regarding the VHA Suicide Risk Identification Strategy screening and assessment program and to describe coordination of suicide prevention-related care following positive screening results. Qualitative interviews were conducted with 40 primary care and mental health staff at 12 VHA facilities. An inductive-deductive hybrid approach was used to conduct a thematic analysis. Several key themes were identified. Primary care and mental health staff participants accepted having a structured process for screening for suicidal ideation and conducting risk assessments, but both groups noted limitations and challenges with initial assessment and care coordination following screening. Mental health staff reported more concerns than primary care staff about negative impacts of the screening and assessment process on treatment. Both groups felt that better training was needed for primary care staff to effectively discuss and evaluate suicide risk. The results suggested that additional modifications of the screening and assessment process are needed for patients already known to have elevated risk of suicide or chronic suicidal ideation.

Vaccine hesitancy among Veterans Affairs Health Care System employees.

Vaccine hesitancy undermines the control of the COVID-19 pandemic and has been observed in health care workers. As part of a quality improvement effort, we aimed to describe reasons for vaccine acceptance and hesitancy among employees in the Veteran Affairs Portland Health Care System (VAPORHCS). We administered an open-ended and web-based survey to all VAPORHCS employees in July 2021. Data were analyzed using a rapid usability framework, whereby qualitative data were synthesized into thematic categories to inform decision making. Among the 1157 employees who completed the survey, 88% reported that they had received the vaccine and 12% reported that they did not receive the vaccine. Over half (54%) of vaccinated respondents reported having initial hesitancy to the COVID-19 vaccine but overcame their hesitancy by deciding that the vaccine's benefits outweighed its risks. Reasons for COVID-19 vaccine acceptance were: 1) individual and community health; 2) protect vulnerable and unvaccinated family members; 3) promote patient and workplace safety; 4) scientific evidence. Reasons for COVID-19 vaccine hesitancy among unvaccinated employees were: 1) concerns with safety and risk profile of vaccine; 2) mistrust in vaccine development; 3) personal choice; 4) openness to future vaccination. These results provide information for tailored vaccine messaging efforts as well as emphasizes the need for trust-building between employees and health care organizations.

Veterans Health Administration staff experiences with suicidal ideation screening and risk assessment in the context of COVID-19.

Universal screening for suicidal ideation in primary care and mental health settings has become a key prevention tool in many healthcare systems, including the Veterans Healthcare Administration (VHA). In response to the coronavirus pandemic, healthcare providers faced a number of challenges, including how to quickly adapt screening practices. The objective of this analyses was to learn staff perspectives on how the pandemic impacted suicide risk screening in primary care and mental health settings. Forty semi-structured interviews were conducted with primary care and mental health staff between April-September 2020 across 12 VHA facilities. A multi-disciplinary team employed a qualitative thematic analysis using a hybrid inductive/deductive approach. Staff reported multiple concerns for patients during the crisis, especially regarding vulnerable populations at risk for social isolation. Lack of clear protocols at some sites on how to serve patients screening positive for suicidal ideation created confusion for staff and led some sites to temporarily stop screening. Sites had varying degrees of adaptability to virtual based care, with the biggest challenge being completion of warm hand-offs to mental health specialists. Unanticipated opportunities that emerged during this time included increased ability of patients and staff to conduct virtual care, which is expected to continue benefit post-pandemic.

Veterans Are Agreeable to Discussions About Firearms Safety in Primary Care.

BACKGROUND: Discussing safe storage of firearms, including access, during times of crisis with veterans in primary care settings may enhance suicide prevention efforts. However, veteran attitudes toward such discussions are not well understood. The goal of this study is to understand the perspectives of veterans on discussing firearms storage safety with staff during primary care visits. METHODS: Individual semistructured interviews with veterans were conducted by telephone, qualitatively coded, and analyzed for themes. The sample was composed of veterans (n = 27) who had positive depression or post-traumatic stress disorder screens and who received care from Veterans Health Administration primary care team members trained to discuss firearms storage safety with patients. RESULTS: Citing the urgent need to prevent veteran suicide, most veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Veterans identified the need for providers to be transparent in their purposes for asking about firearms and to respect veterans' unique relationships with firearms. DISCUSSION: Conducting firearms safety discussions in a primary care setting with veterans who are at elevated risk for suicide is acceptable to veterans when a respectful, veteran-centered, and transparent approach is used.