CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Suicide Prevention Toolkit

CLRM-01
Category: Clinical Risk Management
Published Date: December 2021
  1. PARAMETER GOAL
    1. To provide clinicians with resources and information on suicide prevention.
       
  2. TERMINOLOGY
    1. Assessing and Managing Suicide Risk (AMSR) Training: Teaches best practices recommended by the nation’s leading experts in the research and delivery of suicide prevention care.
    2. Columbia-Suicide Severity Rating Scales (C-SSRS): A standardized suicide risk screen that assesses the full range of ideation and behavior items with recommendations for next steps (e.g., referral to mental health professionals).
    3. Patient Health Questionnaire (PHQ) - 9: A multipurpose instrument for screening, diagnosing, monitoring, and measuring the severity of depression.
    4. Common Terminology of Suicide Behaviors: Refer to DMH Policy 302.13.  
       
  3. MEASURES
    1. AMSR training manual and safety planning interventions: 
      1. "WHEN" to gather information for a suicide risk assessment:
        1. First clinical encounter:
          1. Past suicide attempts
          2. Past suicidal thoughts
          3. Current suicidal thoughts
        2. New or intensified identifiable stressors:
          1. Any stressors involving loss of dignity or self-respect
          2. Recent major life events
          3. Any stressors that triggered previous suicidal behaviors
        3. Change in clinical presentation or mental status:
          1. Increased substance abuse
          2. Decreased hope for recovery
          3. Agitation
          4. Withdrawal
          5. Increased social isolation
          6. Unexplained improvement in affect
        4. Care transition:
          1. Change in professional caregiver, treatment setting, and/or treatment approaches
          2. Quality of relationships with the treatment team or other clients (e.g., trust)
        5. Reports of suicidal ideation, gestures or plans from a credible source (e.g. family members, caregivers, spouses) 
      2. "WHAT" information to gather for a suicide risk assessment:
        1. Background factors that increase vulnerability:
          1. Long-term risk factors
          2. Impulsivity/self-control (e.g., substance use, past suicidal behavior)
        2. Suicide ideation:
          1. Recent/present suicidal intents, plans, and/or behaviors 
        3. Dynamic factors that can change or intensify rapidly contributing to acute risk:
          1. Identifiable stressors
          2. Precipitants
          3. Clinical presentation
          4. Engagement and reliability factors
          5. Client’s ability/willingness to report accurately
      3. Five (5) Areas of Competency:
        1. Approaching your work
        2. Understanding suicide
        3. Gathering information
        4. Formulating risk
        5. Planning and responding
    2. C-SSRS
  4. TREATMENT STRATEGY
      1. Develop jointly with a clinician
      2. Create to maintain individual safety
      3. Begin at step one and continue through the steps until the client feels safe
      4. Easily accessible to the client and clinician
    2. Essential Elements:
      1. Recognize warning signs
      2. Internal coping strategies
      3. People and social settings that provide distraction 
      4. People to ask for help to resolve a crisis
        1. Close family members
        2. Close friends
      5. Mental health professionals or agencies:
        1. Clinicians
        2. Crisis hotlines
            • 800-854-7771
            • Crisis text line:
              • "LA" to 741741
              • Espanol: "HOLA" to 741741
              • Espanol: "442-AYUDAME" on Whatsapp
            • 800-273-TALK (8255)
            • 800-950-NAMI (6264) M-F, 10 a.m. – 8 p.m., ET
            • 24/7 Crisis text line: "NAMI" to 741741
            • 800-662-HELP (4357)
            • For LGBTQ community
            • 866-488-7386
            • Crisis text line: "START" to 678-378
            • Ages 9-20
            • 310-855-HOPE (4673)
            • 800-TLC-TEEN (852-8336)
            • Text: "TEEN" to 839863
      6. Ensure a safe environment 
         
  5. PROVISION OF SERVICES
    1. Determine the need to contact staff authorized to initiate an application for involuntary detention (DMH Policy 307.01)
    2. Implement the Patient Safety Plan
    3. Create the follow-up contact plan to address suicide risk
  6. OUTCOMES AND MONITORING
    1. Client and clinician mutually agree upon:
      1. Need for hospitalization
      2. Implementation of a safety plan
      3. Individualized treatment goals
      4. Cultural appropriateness
    2. An appropriate social support network is established and utilized by the client:
      1. Family and/or friends 
      2. Healthcare providers
      3. Other significant supports
    3. On-going suicide risk monitoring:
      1. Consider risks and strengths
      2. Appropriate level of clinical expertise
      3. Continued building of support networks
    4. Develop and provide direction for continuity of care:
      1. Short-term:
        1. Short-Term Follow-Up: Offered to clients at imminent risk who do not meet the criteria for emergency rescue. The follow-up contacts are made within 24 hours after the initial contact.
        2. Standard Follow-Up: Offered to moderate - high-risk clients. The follow-up contacts are made 1-7 days after the initial contact.
        3. Extended Follow-Up: Offered to clients who received standard follow-up and need continued assistance (e.g., developing a safety plan and/or connecting to resources). The follow-up contacts are made 1-8 weeks after the initial contact.
      2. Long-term:
        1. Continued engagement with outpatient services
      3. Modifications to safety plan and treatment goals
      4. Referrals
      5. Follow-up to primary care providers
         
  7. STAFF TRAINING
    1. Training in Suicide Prevention:
      1. Partners in Suicide Prevention (PSP) Team:
        1. DMH provides awareness, education, and suicide prevention training for clinicians and the community.
            • Suicide Prevention Training for Professionals/Service Providers
            • Question, Persuade, Refer (QPR) Gatekeeper Training
            • Suicide Prevention and COVID-19
            • Assessing and Managing Suicide Risk (AMSR)
            • Anti-Stigma Mental Health Series
      2. Applied Suicide Intervention Skills Training (ASIST):
        1. For all levels of Mental Health staff & community
        2. Explores staffs' attitude towards suicide, provision of hope, and significance of prior attempts 
        3. Participants learn to intervene and help prevent the imminent risk of suicide
        4. 2-day event
      4. ASQ
      5. PSS-3
    2. All staff is responsible for consultation regarding any suicide prevention.
       
  8. SUPERVISION AND CONSULTATION
    1. Contact supervisor or chain of command 
    2. Consult with psychiatrist
    3. Consult with the treatment team
    4. Any staff noting suicide risk should escalate concerns to a supervisor
       
  9. RESOURCES
      1. Weekly Spark – subscribe to receive the latest worldwide research and news on suicide prevention.
    3. Support Groups:
      1. Survivors of Suicide Attempts (SOSA): Support for individuals who have attempted suicide.
      2. Survivors of Suicide Loss: Support for families/friends of those who have died by suicide.
      3. Clinician Survivors: Support for clinicians who have had clients die by suicide.
    4. Resources for families/guardians to support suicide prevention efforts for an individual:
    6. Other Resources