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About half of people who die by suicide in the United States each year had a health care visit in the month preceding their deaths, which means there are opportunities for hospitals and health systems to help patients experiencing suicidal thoughts or behaviors. To improve the way hospitals and health systems identify and care for people at risk for suicide, The Pew Charitable Trusts, in April 2023, partnered with Education Development Center’s Zero Suicide Institute to convene a year-long collaborative learning community called the Suicide Care Collaborative Improvement and Innovation Network (SC CoIIN). The SC CoIIN built on recommendations from the Zero Suicide model for safer suicide care in health and behavioral health systems.
Supported and guided by experts from Zero Suicide Institute, the participating health systems implemented practices to improve the quality of patient care for those experiencing suicide risk by using standardized screening, comprehensive assessment, evidence-informed interventions, and supportive approaches for patients transitioning from a hospital to outpatient care. The following are some reflections from hospital providers and administrators after the year-long initiative:
When Mennonite Health System (MHS) in Cidra, Puerto Rico, joined the learning community, its leaders were struggling with consistency in their universal suicide risk screening. Among the system’s six emergency departments and psychiatric hospital, two different screening tools had been used, leading to inefficiencies. As part of the learning community, MHS aligned the screening tools across its facilities and brought in crisis managers to administer assessments and make referrals, when indicated, if a patient screened positive for suicide risk.
According to Clarrissa Cintron, quality and compliance director for MHS, these changes helped make “sure that the patient was being directed to the service needed. ... Before we joined the SC CoIIN, we already had processes in place for transferring patients [at risk for suicide], but now it’s more of a formal pathway. There’s more communication. I feel that we have filled in some of the gaps that existed previously.”
Trinity Health Grand Rapids Hospital (THGR) in Michigan, part of the national Trinity Health system, sought to improve its screening and assessment practices in two adult medical units. Not all health care workers were trained to screen, and although the providers used a standardized tool for suicide risk assessment, they did not collect or track data. As part of its work with the learning community, the hospital implemented standardized practices for documenting information collected during suicide risk screens and assessments, and changed the way patients experiencing moderate to high risk were categorized in its electronic health record system to ensure that they received appropriate services.
These modifications helped providers determine risk level and decide which interventions would be necessary. THGR also began providing trainings so staff could learn how to ask screening questions, discuss suicide with patients, and encourage patients to seek care.
Casie Sultana, THGR clinical nurse leader in behavioral health, said that the hospital wants to be a place where people who may be at risk of suicide feel comfortable seeking services. “It's a very lonely journey,” Sultana said, “and we want people to come seek help—and feel welcomed when they do so."
Intermountain Health, a Salt Lake City-based health system serving the western U.S., focused on improving its safety planning process in the emergency department and emergency psychiatric center at a hospital in St. George, Utah. Safety planning requires regular conversations between providers and patients about coping skills and supports in the event of a suicidal crisis. According to Kim Myers, behavioral health clinical program manager for the health system, this level of collaboration between provider and patient was not consistently happening before Intermountain Health’s involvement in the learning community.
“A lot of [our] providers hadn’t been trained or felt like [safety planning] wasn't meaningful to patients; it was just another checkbox that they were supposed to complete,” said Myers. But when Intermountain Health surveyed recently discharged patients who had received a safety plan, most respondents indicated that the plan was valuable and said that they had used it or thought they would in the future. As a result, Intermountain Health implemented an evidence-based safety planning tool in July 2023 and set a monthly goal that 60% of patients would complete a safety plan before discharge. In the 10 months from July 2023 through April 2024, Intermountain Health met or exceeded this goal eight times.
In Massachusetts, Cambridge Health Alliance (CHA) also sought to increase the number of patients at risk for suicide who received safety planning before discharge from an adult inpatient unit. In April 2023, only 2% of CHA patients at risk for suicide completed safety plans. As part of the learning community, the CHA SC CoIIN team worked with the system’s social workers to improve this process. Clinicians now initiate conversations about safety planning at the time of admission—instead of at discharge—as part of an ongoing dialogue.
“Having it be more of a co-production with the patient … is what really made the difference,” said Fiona McCaughan, an assistant chief nursing officer. “Now staff regularly go in and talk to the patient, and the team will also give some feedback about items in the safety plan. That has helped the staff get to know the patients better.”
As a result of CHA’s commitment to improving this intervention, by March 2024, 94% of patients experiencing suicide risk had a safety plan at discharge.
Community Fairbanks Behavioral Health (CFBH) in Indianapolis, part of Community Health Network in central Indiana, prioritized improving follow-up contacts with discharged patients in an adult behavioral health unit. “The period after discharge and becoming involved with outpatient care is truly a very vulnerable time for patients and is the most important time to make contact with them and help bridge that gap,” said Aimee Edmonds, director of acute clinical services.
At the start of the learning community, CFBH staff telephoned about 5% of patients experiencing suicide risk within 48 hours of discharge to discuss follow-up care and potential barriers to care. CFBH began collecting data on this process and learned that the communications were well-received by patients—but also learned that contacting people by text message was more effective than doing so through telephone calls. Staff developed a brief text message script asking about barriers to care and providing a phone number for their facility’s crisis department. By December 2023, CFBH had expanded the follow-up communications to at least 30% of patients discharged.
Trinity Health Ann Arbor Hospital (THAA) in Michigan, also part of Trinity Health system, aimed to set up processes to support collaboration among staff to improve the quality and effectiveness of care in an adult medical unit. Although there were social workers on the medical units to provide services for patients with physical health problems, the hospital did not have a dedicated behavioral health clinician working with the psychiatrist to specifically address suicide risk. Staff identified gaps and delays in their processes for comprehensive risk assessment and safety planning, which often occurred because the psychiatrist was unavailable because of other responsibilities. THAA hired a new behavioral health clinician to work with the psychiatrist and social workers on the medical teams and focus exclusively on suicide care.
“Thanks to the SC CoIIN, we have been able to successfully integrate behavioral health and medical services, which ensures safer suicide practices for our patients who are at risk,” said Melissa Tolstyka, the hospital’s director of behavioral health. “This comprehensive approach allows us to bring together both medical needs and mental health needs of our patients and really focuses on improved outcomes and a more effective response to suicide care.”
As part of its work with the learning community, the South Carolina Department of Mental Health added to its team a patient affairs coordinator with lived expertise to help staff members better understand the importance of using nonjudgmental language throughout their suicide care practices.
Having this person on the team “challenged us to really work differently, think differently, and understand that we must have lived experience at the table,” said Allyson Sipes, director of clinical initiatives for G. Werber Bryan Psychiatric Hospital in Columbia. Two units from the hospital worked with the patient affairs coordinator to adopt multiple changes to the screening and assessment processes in their electronic health record system to help hospital staff more quickly identify patients’ suicide risk. They also developed a script and training for clinicians to improve patient engagement during screening and assessment.
The learning community participants came together to transform the way hospitals and health systems care for people experiencing suicidal thoughts and behaviors. As a collective, they demonstrated that it’s feasible to expand and improve suicide care practices to help save lives. Read more about their successes, challenges, and lessons learned in the suicide care journey stories.
Allison Corr works on The Pew Charitable Trusts’ suicide risk reduction project.
If you or someone you know needs help, please call or text the Suicide and Crisis Lifeline at 988 or visit 988lifeline.org and click on the chat button.