Destination Zero

What’s the right amount of time for a crisis care team to stay in close contact with someone who has attempted or is clearly contemplating suicide? Centerstone, one of the nation’s largest not-for-profit providers of community-based mental health and addiction services, is pioneering efforts from its headquarters in Nashville to set the industry standard at a minimum of 30 days. The organization recently received significant grant dollars from state and federal sources for this purpose. All parties involved in its effort—which include its mobile crisis team, a trio of crisis lines and three participating emergency departments—are intent on facilitating the development of enhanced follow-up services that will improve care, lower costs (including reduced traffic to emergency rooms) and result in measurable data showing progress toward a zero-suicide benchmark.

When someone phones Centerstone’s 24-hour toll-free crisis call center today, a staff member (required to hold a master’s-level counseling degree) first asks a series of questions. These range from “Are you thinking of harming yourself?” to “Have you attempted suicide before?” A yes answer to any of them escalates the caller to the Columbia Suicide Severity Rating Scale (CSSRS), a standardized, evidence-based risk assessment that assists in further screening and identification of suicidal ideation. And while this initial engagement is crucial to immediately saving a life, so is a client’s need for improved access to more thorough follow-up support, resource links and behavioral health treatment. A serious matter like attempted suicide doesn’t resolve itself overnight or without dynamic aid.

“Follow-up services and community collaboration are equally integral to preventing hospitalizations and suicide,” says Becky Stoll, Centerstone’s vice president for crisis care services. “Isolation is the enemy of those at acute risk for suicide. The depth and breadth of support can literally be a lifesaver.”

With a $200,000 grant from the BlueCross BlueShield of Tennessee Foundation, Centerstone has already expanded its existing crisis services. Callers assessed as being at high risk for suicide are contacted for continued risk assessment and follow-up plan development within 24 hours of their original call. Subsequent check-in contact is made 7, 14 and 30 days later. Similar outreach is available for individuals hospitalized after receiving referral from one of Centerstone’s crisis-services professionals, as well as for military veterans at high risk for acute psychiatric crises.

Deeper Issues

Further funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) is allowing Centerstone to more aggressively address deeper issues in the healthcare system, namely overcrowding in emergency departments. Statistics reveal emergency room visits related to suicide attempts have increased, while the number of ERs around the United States has decreased by around 15%. Overcrowding can lead to attempt survivors being discharged without having received effective linkage to follow-up care. Suicide risk is high after a failed attempt, and up to 70% of survivors never attend their first follow-up care appointment. This often leads to repeated suicide attempts and cycling back through the ER system at increasing emotional and financial costs.

“We’re fortunate to be in a position now where we are greatly increasing staff, partnering with local hospitals and taking an in-depth look at the effectiveness of outreach and follow-up support in reducing recidivism, suicidal ideation and suicide attempts in those struggling to keep themselves safe,” says Jennifer Armstrong, director of Centerstone’s crisis care services. “Research shows survivors of a suicide attempt are at their highest risk following discharge, and our goal is to support our clients until we’re confident they are safely supported beyond our care.”

With those SAMHSA dollars, Centerstone is creating two enhanced follow-up programs for high-risk suicide clients at different points in life.

Connect-TN is a five-year effort for ages 10–24 that will add six full-time crisis specialists to provide randomized face-to-face, telephonic and text follow-up services in middle Tennessee, as well as phone and text check-in contact statewide. The plan also incorporates collaborative training with select emergency departments, inpatient psychiatric facilities and primary care physicians using the CSSRS. Centerstone will work with each referral partner to educate them and integrate a standardized suicide risk assessment tool; referral partners will make direct referrals into the crisis follow-up program. Leaders will also work to provide cost savings analysis. The program expects to serve 6,000 clients over the 60-month period.

TARGET (Technology-Assisted Recovery, Growth, Empowerment and Treatment) will spend three years reaching out to 3,500 clients in the 25–65 age range. Four full-time employees (two crisis specialists and two “lived experience” suicide-prevention specialists) will provide the same services as Connect-TN but with the notable inclusion of a technology package for randomly selected clients. The latter incorporates the use of iPhones and Fitbits to improve communication and track activities and health habits.

The technology component comes in association with Centerstone Research Institute (CRI), a part of Centerstone’s larger enterprise with which Armstrong works closely to assess the current behavioral healthcare industry landscape and forecast future patterns.

“Working with CRI confirms suicide risk data and helps us move more deliberately toward cost savings and best practices for our team as well as the hospitals and other community organizations we partner with,” Armstrong says.

Working Together

The benefits of emergency departments and crisis centers working together are beginning to gain national recognition. The Joint Commission, SAMHSA and the National Association of Mental Health Program Directors encourage the collaboration. For crisis centers, integration into the formal mental healthcare system adds visibility and credibility in the community plus opportunities for increased funding. Emergency departments experience reduced liability and see financial benefits. Both sides gain from increased information sharing and the end-goal reduction of suicide risk.

Centerstone’s crisis care services are free to recipients and are always ultimately driven by a desired end to suicide in Tennessee, the U.S. and around the world. (Stoll recently traveled to Europe to speak and participate in the first international gathering of organizations committed to Zero Suicide in Health and Behavioral Health Care (see sidebar). As for immediate goals, the enhanced follow-up services being led by Armstrong are expected to result in at least 50% of enrolled participants attending their first behavioral health meeting after a suicide attempt; a 20% or less rate of return to emergency departments; an 80% minimum report of high-risk clients feeling more connected and belonging than before; and finally a 100% reduction of suicides in the follow-up program.

If that goal can be achieved, zero will truly be the hero.

Centerstone, a not-for-profit organization, is one of the nation’s largest providers of behavioral healthcare. Focused on whole-person health, it offers a full range of mental health, addiction disorder, intellectual and developmental disabilities services and integrated primary care. With offices in Illinois, Indiana, Kentucky and Tennessee, the combined organization operates from more than 150 facilities and 220 partnership locations and through a provider network of 400 therapists and counselors nationwide. For more see www.centerstone.org.

Sidebar: Three Things That Help Stop Suicide

The National Action Alliance for Suicide Prevention’s Clinical Care and Intervention Task Force examined four novel and successful suicide-reduction programs and distilled three critical factors that contributed to their good outcomes:

Core values—The belief that suicide can be eliminated in populations under care by improving service access and quality;

Systems management—Taking steps across systems of care to create a culture that no longer finds suicide acceptable and setting aggressive but achievable goals to eliminate suicide attempts; and

Evidence-based clinical care—Delivered with a focus on productive patient/staff interactions.

For more see https://zerosuicide.actionallianceforsuicideprevention.org/.

Take-Home Points

• While initial engagement is crucial to saving the suicidal, so is thorough follow-up care and connection to longer-term resources.

• The Connect-TN project involves randomized follow-up for young people at risk plus training with EDs and other facilities. 

• TARGET will work with older patients and includes a technology package.