Talking Suicide Prevention with Dr. Boudreaux, part 2 of 4
This is the 2nd of a 4-blog post series where Dr. Edwin Boudreaux chats with us about his work recently highlighted by NIH: HEAL Research Spotlight, Taking Suicide Prevention into Primary Care Settings.
Click here to read Part 1
About Edwin D. Boudreaux, PhD:
Dr. Boudreaux approaches the challenge associated with solving seemingly intractable barriers to deliver high-quality behavioral healthcare by working with interdisciplinary teams who have complementary expertise and perspectives and figuring out the right balance between human centered approaches and the use of technology to facilitate workflow.
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Could you talk a little bit about the idea of personalized instructions for suicide prevention?
This is important because in primary care, providers are often very acquainted with action plans for different chronic illnesses. If you have asthma a primary care provider will provide an asthma action plan. The action plan outlines what you should do to maintain your disease and if you’re having an exacerbation, what should you do to handle the exacerbation. In suicide prevention, we have a similar tool, it's called a personalized safety plan. We work with the patient to develop a personalized plan for what they should do if they’re feeling like they’re about to have a crisis, or if there is a trigger or warning sign that they’re having a crisis.
When they’re suicidal, most people have triggers or warning signs, that makes the thoughts about killing themselves much worse. What we try to do, is help individuals be better at identifying these cues and triggers early, and then, take steps to reduce or mitigate that crisis as part of their safety plan. It's a systematic way of starting with things the person can control like internal coping strategies or distraction strategies. It escalates up to the final stage of reaching out to emergency or crisis providers like going to the emergency department or calling the life-line number so they can receive professional crisis counseling.
It's a stepwise approach that helps people think through what they should do. Most important it's written down and they keep it with them. There are mobile apps with safety plans too so people don’t have to carry around a piece of paper. So as a basic bread and butter approach to help people manage their suicidal crisis better, we try to develop personalized safety plans that have been supported by evidence to work to reduce the probability that they attempt suicide.
The plan is usually done by a behavioral health provider. This is part of what poses a challenge in primary care. It can be done by a primary care provider; an advanced practice provider or a physician. They have to be trained, but the training is pretty easy. The biggest problem with the safety plan is that it takes time. It can take at least 15 minutes, maybe up to 30 to develop a really good plan. That's not the amount of time that primary care providers have to spend with a patient. As a result, even though many primary care providers can be trained to do it with good quality, it's often impractical and this is why most of the time a behavioral health provider completes it. If a behavioral health provider completes the safety plan, and a primary care provider is co-treating that patient, they can reinforce the safety plan together. They can know about it, can reinforce its use and it can be a tool that the primary care provider uses even if they didn’t actually create it.
If my office is interested in assessing for suicide risk and developing a personalized safety plan for our patients, can staff and medical assistants help in the process of screening and develop a plan?
Different clinics work differently, and they have different workflows, so what we try to do is build a very flexible structure that outlines what should be done to screen a patient and then if they’re positive (based on whether they’re mild, moderate, or high-risk) what action should be taken for that patient. Then the clinics have to decide the details of that implementation.
As an example, the screener that we use at UMass, is called the Patient Safety Screener. , we call it, the Suicide Risk Screener. It is a 9-item screener, with only 3 mandatory items. If the patient is positive on the 3 items they get asked another 6 questions. This tool is our base tool, we use it in ED, we use it in inpatient units, we use it in primary care. This way the same tool is used throughout the whole system, to help standardize the process and allow us to be able to do the same thing no matter where the patient is treated.
The tool can be used by a medical assistant if the clinic trains and believes the medical assistant can do it. We’ve talked with some clinics that feel very comfortable with their medical assistant using the tool because it’s very structured and involves minimal training to administer. There are other clinics that feel like it’s best for the actual provider to administer and that is fine. As long as the screening is administered by a person who is trained on how to administer, it really doesn’t matter if the medical assistant or the provider does it.
We feel it is dependent on what works best for that clinic, and that’s true for the other components of the mitigation plan. There are components that the medical provider can do and then there are components a behavioral health provider can do. What we’ve done here is we’ve worked with our electronic health record team (we use EPIC) to build all of these tools and the workflow into EPIC. For example, we have a best practice advisory alert that pops up whenever the screener is done and the person is at mild, moderate, or high risk. That advisory is tailored to that risk level. The advisory for mild risk has the types of actions that should be taken. The high risk, of course, is the highest strata, and there is advice on what should be done with the patient.
We try to tailor the advice to the provider as well, to make it a little bit more realistic. It's broken down whether you’re a medical provider or a behavioral health provider. For example, we wouldn’t recommend to a primary care provider that they do a safety plan with a patient, because they’re not likely to do that, but for the behavioral health provider we do recommend. We try to make it so that it’s standardized and structured to provide guidance that helps improve the quality across-the-board, but also flexible enough that it makes sense for the providers.
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In our next blog post from this series, Dr. Boudreaux talks with us about feedback regarding the process and the pilot happening at the moment.
Resources:
https://zerosuicide.edc.org/
https://zerosuicide.edc.org/sites/default/files/suicidesafercareguideforprimarycareproviders.pdf
Edwin D. Boudreaux, PhD
Edwin.Boudreaux@umassmed.edu
Professor, Depts. of Emergency Medicine, Population & Quantitative Health Sciences, and Psychiatry
Executive Vice Chair for Research, Dept. of Emergency Medicine
University of Massachusetts Chan Medical School
