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Steps Along the Pathway – Creating Excellence in Suicide Prevention at Hillside Family of Agencies Disclosures and acknowledgments The author and speaker for this presentation does not have any potential conflicts of interest and is not receiving any financial support beyond salary to disclose content contained here. Agenda - Who is Hillside? Where we started – 2011 Why we transformed our services What shaped our efforts How we transformed our services What we do now What have we learned? Who is Hillside? - Founded 1837 - Orphanage transformed into a multi-system, multiservice provider - Over 110 different services and over 40 locations - 15,000 individuals served annually - Major funders - OASAS, OCFS, OMH, OPWDD, State Ed, Department of Health - Located across Central and Western NY, Prince George’s County MD, Washington DC Where we started – 2011 - “Home-grown” risk assessment tool - Compassion-focused education for employees - Inconsistent pathway for response and care regarding suicidal ideation/behavior - Behavioral focus for chronic suicidal ideation - Unclear plan for how to handle a suicide death - No plan for how to support employee distress - Clinician/RN-centric model, ED-focused model for community programs Why we transformed our services - Garrett Lee Smith Grant – NYS sub-awardee - Agency focus of “translating research into effective practice solutions that create value” - Limited history of deaths by suicide among individuals receiving services, and employees providing supports - Active community partner What shaped our efforts - Recommended best practices for NYS grant proposal 2012 National Strategy for Suicide Prevention Suicide Care in Systems Framework Zero Suicide Initiative Focus on “Culture Change” What shaped our efforts Recommended Best Practices - Universal Gatekeeper Skills – safeTALK, QPR, ASIST - Risk Assessment – Columbia Suicide Severity Rating Scale (C-SSRS) - Safety Planning – Safety Planning Brief Intervention Tool - Postvention – NAMI NH CONNECT Program, Lifelines What shaped our efforts 2012 National Strategy for Suicide Prevention The NSSP features 13 goals and 60 objectives with the themes that suicide prevention should: - Foster positive dialogue - counter shame, prejudice, and silence - Address the needs of vulnerable groups - tailored to the cultural and situational contexts and eliminate disparities - Be coordinated and integrated - addressing health and behavioral health, ensure continuity of care - Promote changes policies and environments - support and facilitate the prevention of suicide - Apply the most up-to-date knowledge base for suicide prevention http://actionallianceforsuicideprevention.org/national-strategy-suicide-prevention-0 What shaped our efforts Suicide Care in Systems Framework Core Values: Beliefs and Attitudes - Leadership leading to cultural transformation – make suicide a “never event.” - Continuity of Care and Shared Service Responsibility – suicide risk must be addressed directly, not merely as a symptom of an underlying disease. - Immediate Access to Care for All Persons in Suicidal Crisis – continuous access to individuals trained in assessment, counseling, and intervention. - Productive Interactions between Persons at Risk and Persons Providing Care – Positive health and behavioral health outcomes are dependent on positive, functional, and supportive relationships. - Evaluate Performance and Use for Quality Improvement – Set a goal of zero suicides, manage system of care performance, and use untoward events as opportunities to improve capacity to save lives at risk. http://actionallianceforsuicideprevention.org/sites/actionalliance forsuicideprevention.org/files/taskforces/Clinical Care Intervention Report.pdf What shaped our efforts Zero Suicide – 7 Essential Elements - Lead – Create a leadership-driven, safety-oriented culture - Train – Develop a competent, confident, and caring workforce - Identify – Systematically identify and assess suicide risk - Engage – Ensure every individual has a pathway to care - Treat – Use effective, evidence-based treatments - Transition – Provide continuous contact and support - Improve – Apply a data-driven quality improvement approach http://zerosuicide.sprc.org/ What shaped our efforts Culture Change Desire to move to a culture where: - Suicide is approached head-on, and treated - Suicide is not seen as a “disruption” to treatment, but a part of treatment - All employees of the agency have an active role in suicide prevention – not the purview of a small group of “experts”. How we transformed our services - Dedicated employee role - Implementation Team - Postvention Work Group What we do now - Offer gatekeeper courses for all employees - “Universal” Screening - Best Practice Tools - - C-SSRS - - Safety Planning Brief Intervention Tool - Suicide Intervention Pathways Emergency Department Diversion Postvention Employee Psychological Distress protocol What we do now Offer gatekeeper courses for all employees - QPR for non-service employees. 1.5 hour presentation - safeTALK for service employees who do not take ASIST. 3 hour presentation - ASIST for employees performing risk assessment and safety planning, as well as any other employee interested in being able to provide “suicide first aid”, in order to create “safetyfor-now” with the person at risk. What we do now “Universal” Screening - The “Clinical Risk Screen” is a multi-topic tool which incorporates questions to identify a number of clinical needs for treatment in the individual being admitted for services. - Questions regarding suicidal ideation and behavior are incorporated into this tool, drawn from C-SSRS Screener tool What we do now Best Practice Tools C-SSRS - International recognized best-practice tool for determining risk of suicide. Can be implemented by a wide variety of individuals, which expands assessment opportunities. Safety Planning Brief Intervention Tool - Widely recognized best practice tool, providing a “brief intervention”, and equipping the person at risk with a self-directed safety plan for addressing future ideation/behavior. http://cssrs.columbia.edu/ http://www.suicidesafetyplan.com/ What we do now Suicide Intervention Pathways - Provides clear guidance across programs and funder systems on how to move through all aspects of care needs of a person experiencing suicidal ideation/behavior - Aligns with Zero Suicide Care Pathway - Addresses “atypical” situations such as: - alternate motivation - lack of engagement in treatment - lack of congruence with external providers What we do now Suicide Intervention Pathways Initial Ideation of Suicidal Risk 1. Preserve Safety 2. Risk Assessment 3. Planning for Safety from Suicide 4. Risk Formulation/Action Plan 5. Treatment 6. Reframing Thinking and Developing Skills 7. On-going Gatekeeper Skills 8. Regular Direct Inquiry 9. Safety Plan Review What we do now Suicide Intervention Pathways Suicidal Crisis 10. Emergency Management Procedures 11. Physical Health Needs 12. Emotional/Behavioral Health Needs Steps #1 - 9 Atypical Situations A. / B. Alternate Motivations - Attention, Revenge, Reaction C. Not Participating in Treatment D. / E. Provider or Parent/Guardian Do Not Agree With the Need For Care What we do now Emergency Department Diversion - Movement from an ED-dependent model for communitybased programs to internal assessment, where relationships have already been established. - Better experience for the person at risk, especially those who have had prior (negative) experience with ED assessment. What we do now Postvention - Agency Postvention Plan merges Critical Incident Management protocols with Postvention Best Practice activities. - 4 domains of activity - Critical Incident Management Response to the Incident - Healing and Recovery - Risk Review and Assessment of the Incident - Pre-emptive Education and Prevention - 5 timeframes for postvention activity - immediately, initial hours after the event, within 24 – 72 hours, on-going after the event What we do now Employee Psychological Distress protocol - Steps for Employees to follow: - Sense changes in your peers. - Assess ability to talk with the peer. - Talk with the peer employee about what has been noticed. - Act to promote safety. - Follow up if the relationship allows. - Steps for Supervisors to follow: - Respond to concerns you identify, or that are conveyed to you by other employees. - Inquire about supports and resources. - Assess what should happen next. - Leverage needed resources and supports. - Act to address performance concerns. - Follow up as long as needed. What have we learned? - Change is hard – especially regarding death/suicide - You cannot over-communicate - Important to reframe concept of “Risk” - “Lean In” to the idea of fear – figure it out, and address it. - Leverage those with passion - There is always another level of detail to define for employees - It always takes longer than you want to make lasting change - Spread the ownership - It takes a whole agency to change what the agency believes and does Special Thanks to: - New York State Office of Mental Health - Suicide Prevention Center of NY - Pat Breux - Garra Lloyd Lester - Gary O’Brien Special Regards and In Memoriam of Fred Meservey Q&A THANK YOU! Tony Hess Manager, Organization Development and Learning Hillside Family of Agencies 1 Mustard Street Rochester, NY 14609 [email protected] 585 654-1328