Suicide Risk: Clinical Training

In my last post I wrote about Aspire’s BHAG (Big Hairy Audacious Goal) of 0 after 5 (zero suicides after 5 years), in a post titled, “0 in 5: Our Suicide Goal”. In that post I outlined our 5 steps to achieving that goal:

  1. Train employees
  2. Supply clinical decision support tools
  3. Engage those at risk
  4. Implement care protocols that will provide the greatest safety
  5. Use data to improve the effectiveness of these over time

In this post, I will be giving an update on our progress and the strategies utilized to train employees. For those with Zero Suicide Initiatives underway,  I hope this post will provide an opportunity for dialogue on best practices and lessons learned for mutual benefit; I welcome your feedback! For all others, I hope you find encouragement from the progress being made and that this post will help you lend your voice to Zero Suicide Initiatives by staying informed and engaged with this issue. So now to the topic at hand…

When Aspire first began working on this zero suicide initiative in mid 2014, we formed a work-group (the opportunity was missed for “A-Team” or “Z-Team”) of clinical managers, crisis manager, and administrators to lead the effort. Before charging into the fray, we spent several months learning about how other organizations are working to improve care in this area.  In doing so, we found some sound advice from peers that suggested we survey our employees to determine what they already know (or don’t) and what their attitudes and perceptions were surrounding suicide.  So we did! We had a tremendous response from our employees, with about 70% of respondents being clinical providers.  Only 39% of respondents reported any classroom (graduate or undergraduate) level training surrounding suicide and 29% reported they don’t always ask about suicide with new clients.  Finally, only 2% accurately reported the number of deaths by suicide at Aspire that year, with 39% underestimating the number and 59% responding “I don’t know”.  This survey gave us a great deal of information about where we were and how to start the training process.

qprAs we analyzed the results of the survey, we recognized a glaring need that had to be addressed immediately, and that was for our front-desk employees. Anyone who comes through our organization is first met by a front-desk support employee, so it was imperative that they knew to recognize the signs of someone who may be suicidal so they can be connected the proper services as quickly as possible. So we began by providing training for front-desk support employees in QPR (Question Persuade Refer).  This is a national training to assist the public in identifying and acting when they encounter someone who may be suicidal.

Building a training paradigm for our behavioral health service providers was no small task. Many of our behavioral health service providers seemed to believe that treatment of suicide risk occurs in an inpatient setting or is best addressed by treating an overarching condition such as Major Depression.  Neither of these responses reflect the most recent research or inpatient discharge data. So we were struck by this question: How do you impart a lot of information, tools, and techniques onto an audience that is spread across 4 counties, among 18 clinical teams, with new clinical employees arriving every week?  We decided on a training program that consists of several tiered training sessions.

Live training was provided by our clinical trainer and a facility director on how to assess individuals for suicide risk.  This was training in large part about how to have the clinical conversation about suicide, what to look for, and when and how to question deeper than the initial response.  It was also designed to supplement our existing online training, while educating employees about misconceptions and information obtained in our survey.

notes-macbook-study-conferenceAfter the trainers made their rounds to teams for the live training, we initiated training in the use of the Columbia Suicide Severity Rating Scale (CSSRS).  The work-team selected this tool to replace our existing, outdated risk factors rating system, because of its researched validity and reliability, widespread use among fellow treatment providers and ease of use and training for clinical employees.  The CSSRS has been identified as the premier tool for identifying those at risk for suicide and developing an initial care plan, and we wanted the best.

We are now in the process of rolling out new treatment protocols, which were developed with the assistance of Jeffrey Garbelman, Ph.D.  Dr. Garbelman is a trainer for CSSRS, and was able to share treatment protocol ideas from other service providers. The workteam has established and is piloting a set of clinical guidelines/protocols to improve the safety of our consumers at various levels of risk for suicide.  Dr. Garbelman endorsed our protocols, and as we implement them and finalize them, he has committed to work with us to seek endorsement by Columbia University. Live training has been provided to our roll out teams about the content of these protocols and they have set out to begin using them.

In the fall we are providing training in Cognitive Behavioral Therapy for Suicidality.  This training will provide clinicians with evidence based training in the treatment of suicide.  This treatment is applied directly to suicidal thoughts and behaviors, rather than working to only treat an overarching condition.

Finally, we intend to wrap up all trainings with one overall final training that utilizes case examples and has the provider apply the knowledge of all four trainings into the review of the care of sample cases.  Sort of a final project, if you will, on using the information obtained in the training.  

These tiered trainings and the details within them are highly complex, require new learning (as well as some “unlearning” of old paradigms) and require ongoing decision at the provider, team, and supervisor levels. For full and effective adoption, we are planning for annual refreshers to ensure skills and knowledge aren’t lost. To assist in that effort we are introducing clinical decision support tools within our EMR.  Built in items like Safety Plans, CSSRS, flagging for high risk missed appointments, protocol explanations, etc will be vital to assist everyone to be on the same page and provide consistently high safety care to our consumers.  

That wraps up our efforts thus far to train staff and our plans to keep them trained in the future in order to know how to recognize the signs of suicide risk and the proper steps to take in order to prevent it.

Stay tuned…more about our Zero Suicide Initiative in future postings!

So what do you think? What is your organization doing to reduce the rate of suicide in your consumers? As a member of society, what do you see as your role in reducing and eliminating suicide? Share your responses to these questions or thoughts and feedback of your own using the comment feature below!

ProfileAbout the Author: Jim Skeel is the Senior Director, Performance and Outcomes of Aspire Indiana. Learn more about Aspire on our website, or on Facebook.

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