Everyone, and welcome to this webinar on applying best practices and care transitions from inpatient to outpatient settings. The panel for today's webinar includes Jack Gettlefinger, Director of Performance Improvement at the Ridge Behavioral Health System, and Megan Williams, the Director of Suicide Prevention Services for CenterStone. Our moderator today is Dr. Julie Goldstein-Grummett. Dr. Goldstein-Grummett is President of Suicide Prevention Strategy at the Education Development Center, Director of the Zero Suicide Institute, and Senior Advisor to the Suicide Prevention Resource Center. Our webinar is sponsored by the Suicide Prevention Resource Center in collaboration with American Psychiatric Association. SPRC at the University of Oklahoma is supported by a grant from the Substance Abuse and Mental Health Services Administration or SAMHSA. The views, opinions, and content expressed in this product do not necessarily reflect those of SAMHSA or the Department of Health and Human Services. There are no financial relationships or conflicts of interest to report for the webinar. Next slide. SPRC is the only federally funded resource center devoted to advancing implementation of the National Strategy for Suicide Prevention. Supported by SAMHSA, SPRC builds capacity and infrastructure for effective prevention by working with state, tribal health, and community systems, as well as professionals, partnerships, and other stakeholders. Next slide. SPRC has the following land acknowledgment to honor and recognize the history of the indigenous people of the areas that now make up the United States of America. I will pause here to give you a moment to read the acknowledgment. We would like to make you aware that the webinar is accredited and implemented by APA, which has designated the activity for 1.5 AMA PRA Category 1 credits. Instruction for claiming credit will be provided at the end of the webinar. Please note that the handout for the webinar can be downloaded from your screen. If you're using the desktop version of GoToWebinar, the file is located in the handouts area of the attendee control panel. If you have joined from the instant viewer instead, you would click the page symbol to display the handout icon. At the end of the presentation, there will be a Q&A period where the audience may submit questions to the speaker. During the Q&A, you can use the questions area of the control panel to ask questions by typing them into the display box on your screen, and staff on the webinar will read the questions, and the panelists will then have a chance to respond. And now it's my pleasure to pass the mic to Dr. Goldstein-Gremitt. Thank you so much for joining us. Thank you so much, Ben. It's really a pleasure to be here. As Ben said, I am the Senior Health Care Advisor to the SPRC, and I hope to share some wonderful resources for you today. Please feel free to use the chat or Q&A throughout this. I am your moderator, but I'm going to open with a little bit of background about what Zero Suicide is and what it is. Care transitions are a really critical piece of Zero Suicide. Next slide. So some of you might be familiar with what Zero Suicide is, but it's a comprehensive approach to identifying and caring for people at risk for suicide in healthcare systems. And as healthcare providers, we really need to think more than just about keeping people alive, but offering them the highest quality of life and care possible. We absolutely use best practices if our loved one has diabetes or cancer or needs cardiac surgery. Suicide care has best practices, and we have to use them. But part of that means knowing who's at risk, targeting the distress and pain and the thoughts of suicide directly, being person-centered, trauma-oriented, and as I said, using the practices that work, that have really emerged in the last 15 years. Zero Suicide is a quality improvement initiative that if you're a high-reliability organization in HRO, this will be very familiar to you and will really line up well with other work that you're doing. It focuses on error reduction and safety. It's both a set of practices, as I've mentioned, but it's also an aspirational goal, right? A lot of people really use Zero Suicide in their lexicon about getting to zero, striving for zero, and I think that's because we think differently. If we're pursuing zero, then if we say we're going to reduce suicide by 10% or 50% and see that reduction as success, that is hard work, reducing anything, particularly suicide, by 10% or 50%. It's very hard work to do, but we think differently and we come up with different solutions if we're really striving for zero. Zero Suicide is about how the organization transforms itself to use the research on what works, using these practices in an ongoing and systematic way with fidelity to constantly ensuring that you're doing the practices in the way that you say you're doing, and applying data-driven decisions to continually update your practices. You're a learning system. It's not the work of a singular clinician doing this, but it's really how the entire healthcare system, and that includes outside of mental health. Zero Suicide is not something that only the mental health department or provider should be doing, but it's how the whole healthcare system adopts and commits to ensuring that suicide practices are thoroughly and routinely embedded across the system and that it really is a core priority for the healthcare system. Next slide. Seven components make up the Zero Suicide framework, each of which has been shown individually to support a reduction in suicide deaths and behaviors. Each of these tools is evidence-based, but as I said, the research is relatively new. Many providers, myself included, were not trained during graduate school to use these. When I was in graduate school, we learned that you should do a no-suicide contract, right? Contract for safety, have the individual promise that they wouldn't kill themselves. That did not give them the skills in any way to support their thoughts of suicide, and there was no legal liability, and it was really very ineffective. A lot of really important research has happened in the last 15 or so years, and we have to embed what we know works. When these components are delivered as a care pathway or a care management plan, then suicide has been reduced by as much as 65% to 80% among patients in care. Suicide care should be just as standardized and supported by a well-trained, well-prepared, confident, competent workforce as we've come to expect for any medical condition, right? Asking directly about suicide, responding appropriately, knowing what to do should be just as routine as having our blood pressure and our height and our weight checked at every physical. If it turned out that you had high blood pressure at the primary care doc, they would pivot, and they would address your high blood pressure, not say, oh, that's not what you came in for, so we're not going to address that today. They would absolutely turn their attention to the most important, pertinent need at hand, and we need providers to do that as well, but they need to have the comfort and the skill to provide this kind of suicide care and then a system that backs that care. This comprehensive approach, Zero Suicide, is currently embedded in all kinds of healthcare systems, including psychiatric inpatient hospitals, integrated delivery systems, hospital emergency departments, community mental health, pediatrics, primary care. All of those are relevant and appropriate settings to adopt and embed the Zero Suicide framework. Next slide. So we have a Zero Suicide toolkit. The website is zerosuicide.edc.org. This is a free resource. It provides guidance on what Zero Suicide is, how to implement it, and it's a comprehensive toolkit to help you roll this framework out. So for example, one of the things that we encourage you to do when you launch your initiative is to take the organizational self-study. This is an assessment of where you stand on a scale of one through five. A group of leaders should be really looking at this self-assessment, taking it and discussing it together. It's a one through five across each of the Zero Suicide components, and it's a really helpful tool to start the kinds of conversations and have a healthy examination about what are we doing? What do we think we're doing? Are we at a five? How can we improve? It also gives you a roadmap for where you can begin. And I also, if you go to the Zero Suicide website, I invite you to join the Zero Suicide listserv. I'll post that in the chat, or maybe one of my colleagues can do that. There are a few thousand people on the listserv, and it's an incredible space to ask questions, share resources, and get advice. It is a really generous group of individuals all learning from one another. It ranges from lived experience to implementers to researchers. And I think people just have learned and discovered a lot, and there's no need to reinvent the wheel. People often share their tools and their resources and their expertise. So I hope that you'll join. Next slide. Today, we're going to be talking about care transitions. And so I just want to highlight a couple of resources that are available to you. And again, I will post this resource in the chat. So this is best practices and care transitions for individuals with suicide risk. It's in the transition section of the Zero Suicide toolkit. And we know that care transitions are high risk times for patients. Research indicates that in the month after individuals leave inpatient psychiatric care, their suicide rate is 200 to 300 times higher than that of the general population. And for many people, that's really counterintuitive. They think that people just got care. Why are their suicide rates higher? But we also know that sometimes that care may not have been suicide specific. Things that cause the distress, that cause the individual to think about suicide, now they're going back to that. It could be in their home or their work or their school or in their community. It takes a long time, and we need treatments that target the thoughts of suicide. And that's not going to necessarily go away in five to seven days, our average length of stay in an inpatient facility. Or as people transition between providers, we know that that's a time that we want people to feel hope and have a sense of hope that their symptoms can be mitigated and that the care will really help them and that the provider really understands. But the waits to see providers are very long, and we need people to stay in treatment with trained providers who can continue to support their recovery by providing the suicide specific treatment. Helping individuals to make successful care transitions to new providers requires education. What's the treatment going to look like? What can I expect? What should I be asking about from my new provider? It requires a lot of support. It requires a lot of hope building and encouragement and education to the family. And it isn't enough to hand the patient a discharge summary. Here, go to this appointment or call one of these phone numbers. With appointments already scheduled, when they don't really understand what the next level of care will look like, things like transportation and childcare, where the agency is located, what somebody's work schedule is, these can all be really significant barriers to keeping these appointments. And the burden is on the healthcare system to understand what is most likely to lead to a successful care transition for the individual and take all of that into account as best they can. We can't set patients up with knowing these barriers exist and then blame them for not attending to these appointments or not going to providers when they really didn't know what to expect or the provider isn't well skilled in addressing their needs. So this document was developed by the National Action Alliance for Suicide Prevention in 2019 with the support of universal health services. It describes evidence-based practices for improving clinical care and outcomes for people with a history of suicide risk during this really critical period of transition from inpatient to outpatient. And our speakers today will be describing many of the ways in which they've improved safety and continuity of care for patients during this transition using the best practices described here. Next slide. So some of the resources in this report are things like a two-page executive summary, which provides an overview of best practices and care transitions. We have a care transitions video about highlighting the importance of implementing best practices, an infographic to illustrate these key points. But we also have an outpatient care self-assessment and an inpatient care self-assessment, kind of similar to what I was describing for the zero suicide self-study. You see here the self-assessments, and these are designed to help providers measure their current practices and policies and best practices outlined in these recommendations. It's a great place to really begin to see where you are and where you can go to. The other resource, next slide, is an action planning template. So now that you've learned more about what you do, where can you go? What can you do next? So I really encourage you to look at this resource after today's call. And I think that our speakers will give a lot of information about how they were successfully able to accomplish care transitions with their patients. Next slide. Finally, here's a resource that can be shared directly with families or the individual support network about their role in supporting their loved ones. So similar to a safety plan, if you develop a safety plan for an individual and say you have to call, let your spouse, let your friend know if you're really having thoughts of suicide, the spouse or the friend needs to know what to do if the individual comes to them saying, I'm really having some distressing thoughts. They need to be educated about what to do. It can't just be call your clinician, call 988. The families need to understand how to be the support that the individual needs. Families often absolutely want to help, but they just don't know frequently what to do, and they're afraid of doing or saying the wrong thing. And as I said, sometimes families also believe inaccurately that the hospitalization might've fixed the person. So much like any other surgery that requires extensive recuperation at home, so does the period of time after discharge from a hospital. There are new medications, there are new providers, there are new appointments. It can be a lot to remember and to digest. And families are really critical in helping the individual to navigate where they need to go to support them. But that education needs to come from the healthcare system and the provider about what to expect and really what is realistic and how best to help and support. So this is a tool you can even share directly with families and certainly with your team. Next slide. So let's turn to today's webinar. The learning objectives are to identify care transition best practices for inpatient and outpatient settings that can be applied in your organization. Describe how care transitions best practice implementation tools can help inform practice improvement and training within your organization and discuss the importance of family involvement in planning for care transitions. Next slide. Our first speaker is Jack Gettlefinger. Jack is the Director of Performance Improvement and Regulatory Compliance at the Ridge Behavioral Health System, calling it the Ridge. It's a private freestanding psychiatric hospital and outpatient system in Lexington, Kentucky that specializes in the treatment of psychiatric substance use and co-occurring disorders. Jack has overseen the Ridge's Quality Assurance and Performance Improvement Program since December of 2020 and has served in many positions in that agency. So I'm going to turn it over to you, Jack. Hi, Julia. Thanks so much for that introduction. I'm excited to share with you all today. Again, my name is Jack Gettlefinger, the Director of Performance Improvement and Regulatory Compliance at the Ridge Behavioral Health. We're a 110-bed hospital located in Lexington, Kentucky. The purpose of my presentation today, what I'm wanting to communicate to you all is what the Ridge, an inpatient hospital with an outpatient extension, is currently doing to reduce gaps in care through ongoing connections and a strong continuum based on best practices strong from our Care Transitions Initiative and our participation in the same. And hopefully by the end of this presentation, what we'll be able to do is pull a couple of insights from our own experiences and apply them to your own care settings. But first, what I'd like to do is just reflect briefly on how the Ridge became involved in this partnership with the Zero Suicide and Care Transitions Initiative and how we partnered with the National Action Alliance for Suicide Prevention to make that happen. After I review our brief background, I'll kind of walk through the steps of how we became involved specifically in the Care Transitions Initiative and some of the fun steps that we have implemented at our own facility. Next slide, please. Our journey began with the development of the Facility Zero Suicide Initiative. In 2016, the Ridge began a partnership with the National Action Alliance for Suicide Prevention to implement Zero Suicide, an initiative focused on ensuring that the system of care we provide to patients at risk of suicide is effective, caring, and competent. Universal Health Services, or UHS, which is the Ridge's parent company, led the nation as the first inpatient behavioral organization to implement the AMSR framework, which stands, of course, for assessing and managing suicide risk. The key focus areas of implementation involve comprehensive suicide risk assessments and reassessments, discharge planning that begins at admission, crisis safety plans for all patients assessed, and an evaluation of safety risks in the physical environment with an intention-driven culture shift based upon the philosophy and belief that one life lost is too many. All too often, patients want gaps in our behavioral health care system leading to increased suicide risk and potential loss of life. As an inpatient provider of behavioral health, it's our job to ensure patients remain safe while they're under our roof, but it's also our job to ensure they remain safe when they return to the community. And again, that's the serious responsibility and challenge that we're charged with on a daily basis whenever we discharge a patient from our inpatient level of care. And so, in 2021, the Ridge continued its partnership with the National Action Alliance for Suicide Prevention to participate in a care transitions pilot and join an important discussion regarding best practices in care transitions for individuals with suicide risk. Next slide, please. All right. To begin, I'll just kind of go over how we initiated this conversation and project at our facility in partnership with the National Action Alliance. As Julie mentioned, we actually utilized as a team the Zero Suicide Inpatient Organizational Self-Study to identify areas of strain and opportunities for improvement. And it's really conveniently organized by category, where you can write yourself on a scale of one to four and assess how well you're doing in each of these areas. And what's really great about the tool, in addition to being able to identify opportunities for improvement, is we're able to pat ourselves on the back and take a second to look at the extensive amount of things we do as an organization well. We do so much in healthcare as organizations on a daily basis for our employees, our patients, and our clients, and sometimes it's good to reflect on all the things we do well. At the same time, we were able to effectively identify opportunities for improvement. The following areas on the screen are what we decided to address. First, involve other supports. Second, focus on electronic delivery of essential records to the next level provider. Provide ongoing caring contacts to the patient. And finally, consider innovative approaches for connecting the patient with the outpatient provider. Next slide, please. So, let's start with involve other supports, which is the first category we attacked as a team. We pulled a PI team together, which consisted of me, the Director of Performance Improvement, as well as our Director of Clinical Services, the Head of Nursing Leadership Involvement, as well as our Director of Utilization Management, our CEO, and of course, our Director of Outpatient Services. And on the self-assessment tool, involve other supports, this category is identified as good consent, engage, educate, involve a network of supports the patient has identified. And so, what we wanted to see as a team is, how well are we doing in terms of involving the patient support person at admission in the discharge plan? And how frequently is the support person supportive of the patient's treatment during their treatment on an inpatient basis. So we conducted a facility chart audit of psychosocials on our adult services units. We have both an adult psych and a substance use disorder unit. And in conducting this audit to see how successful we were in contacting the patient support person, we did identify particularly low success rates on our substance use disorder unit, a little bit lower than we'd like. And so this is the area we decided to focus on. And for the substance use disorder population, they tend to have a more fragmented, fragile support system due to the nature of addictive disease, the stigma attached, and the social context in which it presents when a patient seeks help. Patients may not have a support system, or they may refuse a client contact due to a deep sense of guilt and shame. And again, the substance use disorder population is certainly not immune to suicide risk, in addition to relapse. And so they require the same level of support upon discharge. As a team, we evaluated what we could do to improve in this area. And the following steps were taken to increase contact with the patient support person on this unit. And the reason it's so critical is because involving the patient support person in the discharge plan is one more safeguard. It's a critical area to have a support system in place for patients admitted with severe depression, anxiety, substance use. Having that one more safeguard in place is critical. So first we coach the therapist with messaging used and initial contact with the patient. First, the therapist references the release of information in the patient chart to see if the patient has a support person that can be identified. Second, what we coach the therapist on is if you didn't make treatment, the therapist should communicate with the patient, quote, as part of your treatment plan here at the Ridge, I'm going to be contacting blank and serve support person. And what this does instead of asking the patient if it's okay is it kind of shifts the language to ensure that the patient understands it's part of the treatment process. Again, what's so essential about this is using clear language with the patient and communicating reasons for contacting the support person. If there's any hesitancy or reluctance. Now, if the patient initially declines, we encourage the therapist to follow up with the patient once two days later. If consent to contact the support person is given, we just ask that we ensure the documentation chart reflects more than one attempt to contact the support person if unable to reach them initially. We also discussed offering parameters with the patient and documenting that on the release of information in terms of what information can and cannot be shared with the patient support person. And finally, what we did is we worked with intake staff to prioritize obtaining a contact on the release of information at admission, also working with the patient to use the same person listed as the emergency contact if needed. Now, if the patient indicates having no support person while back on the unit, the therapist can also utilize the emergency contact as a reference and have that as a potential discussion with the patient to see if they can use that support person. So, all in all, frequency and contacting the patient support person after education of the therapist and intake actually increased by 30% in the Substance Use Disorder Unit. And we anticipate that will continue to improve this unit and enforce the importance of clear communication and engagement with the patient at admission across departments and disciplines. Next slide, please. The next category that we focused on addressing was electronic delivery of essential records. The self-assessment tool describes it as ensuring the outpatient provider receives copies of crucial records before the patient's first visit. In 2021, vaccine records to the next level provider within 24 hours of discharge was a regulatory requirement that we struggled with, but it's still an essential piece of a safe discharge for every single patient to ensure that the next level provider can make well-informed decisions based on a patient's inpatient study and treatment. So, at the time, we were probably trained in about 60 to 80% compliance, month to month, with making sure those discharge records were making it to the provider within 24 hours. And as a team, we pulled our heads together and identified three basic but very critical steps to fix this process and ensure it was consistent and timely in getting those essential records to the next level provider. At the time, there were no clear roles and responsibilities identified. And so, first, we needed to create a process that covers weekdays and weekends. Second, we needed to make sure we assigned clear roles and responsibilities. And finally, three, assure backups are in place. We found that visuals were very effective in communicating processes, roles, and expectations to our staff. And so, the visual you see on the screen was posted on each unit in the nurse's stations in our hospital to make sure they were clear on the assigned roles and responsibilities, as well as how it was assigned on weekdays and weekends. We also educated and coached our staff on our whole streaming educational platform. And what we saw was an increase in compliance to about 90% or more month over month after about a three-month period. And this was due to the fact that we used clear communication visuals on the units and had our medical records team audit every single chart at discharge to make sure that the patient had essential records to the next level provider. The process basically works by having the unit clerks assigned as responsible on the weekdays on both their adult and services to back to strength records. If that position is to be backfilled and run off, then the case coordinator backfills that position. They're part of our utilization management team. On the weekends, our receptionist manages vaccine and at discharge, the nurse brings the patient to the front, brings the essential records to the switchboard, and then they fax them out as they're the insistence that they will depend on that process. Next slide, please. Next category that we addressed was provide ongoing hearing contacts to the patient. The self-assessment tool describes it as this. Hearing contacts are encouraging notes and messages that do not require an actionable response. Every patient discharged home from our hospital receives a journey letter signed off by our chief nursing officer and personalized with the patient's written name. There are two types of journey letters, two categories. One is called the journey of hope and that goes to our adult and psych patients and any patient that was admitted for a substance use disorder. Concern and diagnosis receives our journey to survival. And this letter is basically a brief touch base and offers resources within our continuum should the need arise. And this can include coping skills relative to the diagnosis, as you can see on the screen, and also includes contact information for our inpatient and outpatient services. Shortly, we'll also be adding the 988 emergency number to promote greater awareness surrounding that resource as well. And, you know, journey letters are a source of great private privilege for a couple of reasons. One is just the personalized touch that the patient is receiving something by snail mail and it's got their written name on there, it's signed off by the chief nursing officer, and it's creating an ongoing link to the patient. There's no action required by the patient, but it shows that we care about our clients. And in addition, this ongoing link is extensionally creating the ongoing discharge. It's providing one more safeguard, one more resource for the patient in their most fragile state, which is upon discharge from the inpatient hospitalization. Our receptionist manages these and sends them out on a daily basis in coordination with intake. Our admissions department provides the receptionist with previous day discharges and then sends them out that next day. And so we will continue to do that. And we've also considered electronic delivery of other resources to the patients. And so we'll continue to evaluate innovative ways to continue to really connect it with our patients when they discharge our inpatient level care. Next slide, please. Within our system, we're constantly looking for opportunities to expand our service line to increase access to care. During the pandemic, that meant increasing and expounding chronic telehealth capabilities and also strengthening relationships with our schools that host our school-based partial hospitalization programs. We offer both PHP and IOP services for adult and youth in addition to several building opportunities. Shortly, we'll also be offering medication-assisted treatment to expand our continuing growth. Step-downs to an outpatient program from an inpatient hospitalization can be an essential piece of a safe discharge point for our patients. That's why the graphic on the left is posted on each unit in our hospital so that conversations regarding a potential step-down can begin early on. We actually created a position that can assist with facilitating smooth uninterrupted transitions to our outpatient programs. And that role is known as the step-down coordinator. And what the step-down coordinator does is continuously communicate with patients on unit during their stay. They also identify patients qualified and eligible to step down, and they also assist in the process. Ideally, 100% of eligible clients step down and start an outpatient program on the day following their patient discharge. Sometimes the step-down coordinator even attends the patient's first treatment team in the outpatient program, as they also serve in a hyperbole as the case manager. The average triage rate of eligible clients here today for our facility is about 26%, which we're very proud of, and that exceeds the industry benchmark. Implementing medication-assisted treatment will assist in retaining patients within our continuum as well. As one of the reasons patients typically decline the step-down program, if they're in a substance use disorder program on an inpatient basis, is they're already connected to a community resource like medication-assisted treatment. So we're very proud of our outpatient program and continue to expand and make sure that transitions from an inpatient program to an outpatient program are as smooth and uninterrupted as possible, so that the patient has a secure and safe discharge plan. Next slide, please. A final note that I'd like to touch on, discharges against medical advice are inherently dangerous. Regardless of the healthcare sector, whether psychiatric or medical, this can mean the difference between the readmission or sustained improvement and stabilization. It can mean the difference between a positive and a negative patient outcome, or it can mean the difference between life and death. So at the ridge, evaluating opportunities for improvement, we did identify that we can improve in this area regarding our request for discharge policy and procedure. Requesting a discharge from an inpatient hospitalization for psychiatric or substance use disorder and health issues should be a real solid process. It should be an intentional discussion on risks and benefits. Of course, at all times, all disciplines should be involved. The ultimate outcome should be patient-centered and physician-driven. And when a patient decides to end their treatment prematurely, we must ensure we craft and optimize the safest discharge plan possible, given the patient's situation and home life. The 24-hour notice of intent to leave form was implemented to change the language in messaging surrounding discharges against medical advice. It replaced our request for discharge plan, request for discharge form, excuse me. And it basically notifies the patient that they will be seen by a provider within 24 hours. If they've requested an unplanned discharge, they can stick the reason on this form. It was not a drastic change in the intent of the form or the policy, but more so the change in the language of messaging and how intention-driven or facilitating the appropriate discussion with the patient. Making sure, you know, that 24 hours is critical because the provider needs time to review the case. The therapist and reception have the opportunity to conduct motivational interviewing with the patient if the treatment team believes that it's not the patient's best interest to discharge prematurely. And this also ultimately allows the therapist to craft a safe, secure discharge plan for the patient if an unplanned discharge were to occur. So again, the policy on AMAs did not vary or change drastically, but the language, messaging, and intentionality behind the process was reformatted to prioritize patient safety. Again, as you can see, it's titled Notice of Intent. It's just, it's a little bit different. And so this is still a work in progress for us. And we believe a lot of factors plan to request for an early discharge. This can include unit program speed, fidelity, consistency, as well as an interdisciplinary treatment team that prioritizes patient participation and input into the treatment plan. But ultimately, changes like this to make the culture shift in the way the team views patient care and suicide prevention across departments and disciplines. Every member of the treatment team from the nurse to the therapist to the provider needs to be onboarded to the philosophy of zero suicide and the process that should be followed. Implementation of forms is simply not enough. Zero suicide and the effectiveness of the care transitions program comes from the very top down as a leadership team. Leadership must always go play. Staff education and provider buying is essential. And now in 2022 as a hospital, more than ever, we're challenged and charged with responsibility to protect at-risk individuals in our community by reducing these gaps in care and utilizing every single resource at our disposal to ensure a patient's safe and continued discharge. Thank you. Thank you so much, Jack. I think that was so interesting to hear how you actually are implementing and making real-time changes. I love the paperwork change on AMA to leaving and being more intentional about seeing people, the languages more sensitive, but also the plans in place for what are you going to do so that you ensure somebody is still safe. So I think these were some great ideas. And I want to hear from other people using the Q&A box. What were some key takeaways you're walking away with that you're going to go back and share with people around you? You can type your thoughts right into the Q&A. I saw somebody say, I really like the forms and it gives a great way to change the language of how we talk about discharge. And the journey letter, isn't that great? I think it's so important to, we know from research that those caring contacts are really critical. They reduce suicide. They let people know that they have a place to return to. They know what their next steps are. They know that they are cared for. Other people saying they also like the caring contact letter. I see a few questions, but I'm going to hold off a little bit till we get to our Q&A at the end. Lots of people loving your journey letters and that it includes coping skills. There are examples of caring contacts on the Zero Suicide website. So want people to know that you can look in the Zero Suicide website, maybe Adam or Julia, you guys can find the page that has the examples and put that into the chat. I know that we have some language to help you if you want to start using caring contacts. I like the support for children and adolescents, especially as they return to school in public and independent schools. And this is what it sounds like Michael's doing in LA County. So great examples. Thank you. Yeah. Hope that people are going to leave today fired up, ready to talk to their colleagues about how to get started using some of these resources and ideas. So I'm going to turn it over now to Megan. Please feel free to keep typing some of your takeaways, keep bringing in questions, and we'll get back to the questions towards the end. But first, I want to turn it over to Megan Williams. Megan is the Director of Suicide Prevention Services for Centerstone. She oversees the organization's suicide prevention efforts, including providing outreach, education, and enhanced follow-up crisis services. She manages the agency-wide operations of the suicide prevention pathway throughout Centerstone's locations in Tennessee. And thank you so much, Megan. Thank you. Yeah, so I'm Megan Williams. Hello, everybody. Thank you so much for spending your afternoon this Thursday with us. As was mentioned, I'm part of Centerstone. We are a large behavioral health organization with locations here in Tennessee. I'm based out of Nashville, Tennessee. We have locations in Illinois, Indiana, and Florida. And here in Tennessee, kind of our bread and butter, if you will, is outpatient services. We have a little over 20 clinic locations across middle Tennessee and southeastern middle Tennessee, as well as crisis services. We're a contractor for 988, the National Suicide Prevention Lifeline. And we have been an adopter of the Zero Suicide Model really since 2014 is kind of when we got everything kind of coming together for a long time. So in thinking about how to really kind of analogize how I view and how we kind of view the care transitions portion of what we do between, you know, the wonderful work that Jack just demonstrated through their work at the Ridge, and how we ensure, you know, proper and safe transitions to the outpatient facilities like we are, I kind of thought about being kind of a part of a relay team, you know, where, you know, we in terms of inpatient outpatient facilities, and really even, you know, crisis response departments, crisis centers, all kind of mental health and behavioral health organizations are kind of all part of this big relay team, right? Like our goal is to improve the behavioral health and the mental health of those we serve. And that kind of is what the baton symbolizes is, is our clients or patients who we serve and making sure that as we kind of from one runner to the next from the inpatient facility to the outpatient facility, making sure that we have that appropriate, timely, secure transition for them as they're stepping down from inpatient into outpatient treatment with us. And how do we do that? How do we make sure that, you know, what we're doing is really securing that baton, securing that client and making sure that they're ready and when we have them prepared to come to us. So I'll talk through kind of some things that we've done in the past. And then I'll also talk through, we utilize the self-assessment study through the Action Alliance. And it was really, really helpful to sit down and kind of talk through and create some structure around, here's what we know we're doing pretty well. Here's where we think we can improve. And here's some things that we can implement moving forward, just as Jack did with some of their implementation procedures. Next slide, please. So I'll talk about each one of these kind of in more detail, but, you know, ensuring a successful handoff, you know, it's so critical. How do we make sure that that is done well each time, each baton, each client that we have to pass off, right? Developing strong relationships with the local inpatient providers, engaging that client before they ever discharge from the hospital in that inpatient facility and collaborating not only with them, but with other family members, just as Jack was mentioning, you know, making sure they have a support person to identify, making sure we are communicating with them as well. And then providing some of those same caring contacts or similar caring contacts that Jack mentioned. Next slide, please. So that first point, they're developing relationships with inpatient facilities. I can't stress this enough how important it is to do this. I'll talk about, you see there mentioned the hospital liaison program and how we've been able to do that in some of our local inpatient facilities through that program. But really just in general, you know, having folks meet with each other in terms of maybe your medical leadership with the inpatient facilities, medical leadership, maybe some administrative folks, those who will maybe be handling, you know, health information management, documentation, those sorts of things, making sure everybody kind of on both sides has the correct contact person, who to reach if they're struggling to receive discharge paperwork, you know, all that stuff of that set up initially, that can really help you in the long run, making sure that things are running smoothly and day-to-day operations of things are happening at the beginning. You know, what are the processes? What would work best? Those sorts of things can really be helpful. At Centerstone, we have, we call it our hospital liaison program. And through our state Medicaid office, we were able to receive some funding that really we have designated staff who are liaisons and they're basically embedded in inpatient facilities here in Middle Tennessee. And they really serve as the point of contact, both for the inpatient hospital and the discharging client and their family. They have kind of regular and sometimes ad hoc meetings with inpatient hospital staff to maintain that strong coordination of care. So things like, Hey, you know, last time around, you know, that last relay race, we struggled to, we kind of bobbled the baton, right? How do we make sure that it's less clunky this time around, or what are the processes that we can kind of fix and work on? And how can we improve and make an even better time in the next race, right? Really ensuring that the discharging client is fully linked outpatient services. Coordinating that scheduling and the discharging client and their family members with Centerstone staff is really, really important. We work really closely with the discharge planners and the inpatient facilities to make sure, and we talk to families as much as we can to make sure that their outpatient appointment is scheduled at an appropriate time, at a time that they can come where they have transportation, or maybe they don't have a consulting appointment somewhere else. And those sorts of things to really make sure that we can keep that client engaged and get them in our door, right. Make sure that we can have full secure responsibility of that baton. Once we, once we get them in our full possession, right. And then providing that appropriate follow-up upon discharge. So there's kind of a lot of moving parts. I'll go through a little bit more detail here as well. Next slide, please. Engaging and collaborating with the clients prior to discharge. Like I mentioned, all of our liaisons prior to the client discharging from the inpatient hospital where they're embedded, they will meet with that client and try if they can to meet with clients, family, if they're available as well, or call them on the phone and talk to them about really building rapport. We really view this too as a little bit of customer service, making sure, you know, we might be their first impression of an outpatient facility, making sure that they really have a good kind of first impression of us that we set the expectations for that initial appointment and talk through them, talk about it with them, talk through kind of what they might need to bring, what to expect. Can they bring a family member with them? Of course, we encourage that those sorts of things, getting some of those ROIs and doing a little bit of that stuff up front so that the initial maybe hospital discharge intake and the outpatient facility is not so cumbersome all the time with somebody who might be a little bit more vulnerable coming out of the hospital. So really making sure to try to build that rapport. Again, you know, in terms of that relay race, there's a point in the race where if Jack is, you know, the second runner and I'm the third leg, you know, we're kind of, we kind of both are holding onto that baton and I'm starting to run as he's kind of putting that baton in my hand, really making sure that we, as we're kind of both holding onto it, that he's holding onto it securely. And then we are doing what we need to do to make sure that we can successfully say, okay, Jack, you can let go now and we've got it. There's a part where we're kind of both work together, which I think is really, really vital in terms of making really good care transitions work between, between the relay runners. Right. Next slide, please. Caring contacts, which Jack mentioned. I know Julie talks about this as well, and we just really can't stress this enough, how important caring contacts are. They're, they're just really, really, really impactful with folks to, to let somebody know, Hey, we're thinking about you. You know, it's non-demand, right. We're not necessarily asking you of anything, but in part of that, we do appointment reminders, you know, the hospital liaisons and center stone, our support staff really work really hard to make sure that we're getting the right information to the right people. So we can help you get that information to the right people. And then center stone, our support staff really works together. Our liaison will try to give a call to the folks and remind them, Hey, you know, you're discharged yesterday. Your appointment with us is in two days. Does that still work for you? If it doesn't, we can help you warm transfer to our, to our department and get you rescheduled in a different day. Constantly kind of being in contact with them. Because it can be clunky sometimes between, okay. You've been discharged from the hospital on Sunday. Your appointment with us is not until the following Thursday. So we can help you get that information to the right people. And then our liaison will try to remind you, we're not asking you to come in a week. We need to make sure that you're okay. And that very vulnerable time. Post discharge to make sure that we can. You know, have that successful handoff. If a client does not show for that initial appointment. So if it's Thursday and they don't show. We ask that. You do a caring contact in real time. So if somebody was scheduled to come and see you at 1130. We do a follow-up care in contact. So we do a follow-up care in contact. With that therapist who is supposed to see that client. Gives them a call in real time and tries to get them rescheduled. And then we do some follow-up care in contact through our support staff as well. Through clinicians, supervisors, support staff. Something I did want to, want to mention too is trying to make sure to get some data. Around this, if you can, you know, implementing some of the stuff. That's something that the self-assessment really. You know, we're trying to make sure that all of the things that we're trying to implement are measured and are measurable. So that we can really see kind of. What impact it's making. Is it working? Is it not working? Do we need to make a tweak here and there? And we found we did some research. We are not in our hostilities on program is not in every inpatient facility and in the Tennessee area. So we have a lot of folks that are coming to us. And we're trying to figure out how often. The folks in the hospital to the time they come to us are, how, how can I showing up versus those who are not receiving that care in contact? We there's about a 32% difference. 32% more folks are showing up for their hospital discharge appointment with a current contact. Versus only 15% of folks are coming without one. So we really can see. And it's a good question. I think that the show rates are something that we constantly talk about in the outpatient world. Some of y'all might be like nodding your head, even though I can't see you and saying, Oh yes, this is a struggle. All of this. Information and some of the self-assessment that we've done has really helped us to think about how we can do that. As Julie mentioned before, the burden is on the healthcare system. We have this responsibility. We have this responsibility to make sure that we're doing things right. And that we're doing things right. And that we're doing things before and after we have kind of that leg of the race and making sure that we're responsible at all times. And doing what we can to really help that client finish, get to the finish line. Right. Next slide, please. So we feel like we're able to do a lot through our hospital liaison program. It's really shown us, you know, we've had a lot of great success in the past. You know, we've had a lot of great success in the past with our hospital. Leadership and our hospital. A lot of them have been very helpful. They've given office space. We we've developed really good rapport with them. Where they will just call up our hospital liaison and kind of almost like case. Case staff with folks and see what we can do. We can kind of help them. You know, Then we can kind of on the flip side, be an advocate for that client coming in. We can kind of help them get the job done. So I think it's really been nice to kind of. The study is really helping us do a lot of good stuff. But in doing this, Self-assessment to the action alliance and SPRC. You know, myself and a few other people. And our quality improvement department kind of got together and really kind of walk through the self-study. That really helped provide a barometer of where we are. Where we've been and what we really feel like we can improve upon. It really helped us. And for some decision-making support. You know, we've been doing a lot of self-assessment for a while. It kind of got us to think through, you know, we really think we can do a few things. That we can implement really quickly. And then it also kind of helped guide us and more of like a long-term, like a 50,000 foot view of what we want it to do. Kind of long-term goals as well. So, like I mentioned, we really kind of reviewed this as a group with our quality improvement department. And then we kind of went through it as a whole. And identified, you know, kind of who needed to take on the responsibility within our system. How, how we could implement that. And really outline. Those action steps and make sure that those goals were attainable. And can we build upon those? Like I said, for future, more long-term goals that we see where we'd like to move forward. Next slide, please. Okay. So kind of us running with a baton, right? How do we make sure that when it's our turn to run the relay race? What can we do? What are our action steps? Just as Jack mentioned where they made some changes to their. I think they call it the intent to leave document instead of kind of like AMA against medical advice. That language and stuff. We kind of found two areas where we felt like we could really improve. The first thing we really thought about in terms of care transitions, continuing outpatient treatment. Everybody who's scheduled for a hospital discharge appointment, whether it's a hospital discharge intake, or maybe it's somebody who's previously been in services with us. We automatically enroll them into our suicide prevention pathway. This is really kind of where our zero suicide model has been born from. Because as Julie mentioned, we know that folks coming out of the hospital of an inpatient psychiatric facility. They're 200 to 300 times at higher risk for suicide in that first month. And we really want to make sure that we're being as protective as possible again, making sure that we're really securing them when they come in to see us. And when that discharge appointment is missed, you know, we have the care in contact to the liaisons and through the support staff, but really focusing and targeting on making sure that our outpatient clinicians, when an appointment is missed, they're calling that client in real time. And when they mark that appointment as a no-show in our system, it flags that and we can run a report to see, you know, how many people would the coded hospital discharge appointment where Marcus did not show versus, you know, how many people were called versus how many people were not called. And that helps us with training to staff to remind them, Hey, you know, making sure that you're calling them in real time and providing a caring contact in real time. And then we also want to see you and our support staff kind of based on the size of the clinic location to really follow up with them. And upon the third, the third attempt, we also send out a caring letter. I think ours is based off of some of the things that you've, you can see on the Zero Suicide website, again, non-demand caring contact. We missed you for your appointment. Here's our number. If you'd like to reschedule, you know, just getting that piece of mail and getting kind of a non-demand, Hey, we noticed that we missed you. And we've had clients say, you know, I know you kind of said you were going to call if I missed, but usually, especially in a bigger system, like you just kind of don't think of yourself as important to people. And we've had clients kind of be surprised that we've called them. Hey, you know, this is Megan. I'm calling you. You were, you were scheduled with me 15 minutes ago. I just wanted to check in and make sure everything's okay. And they're a little bit shocked that we're even calling them and it's kind of showing them, Hey, we care about you enough to notice that, you know, you missed your appointment and we'd love to see it. We'd love to get you back into services. So that's been something that's really, really been helpful for us in terms of engagement and building that rapport and helping them along in their, in their process. Right. And then the second thing we've done based off of that self-assessment and some of our action plans is, you know, something that's asked on that peer transition action plan is making sure, you know, how well are your staff trained in evidence-based practices for suicide prevention? And we felt like we were okay, but that's, that's something that we had been talking about for a really long time anyway, in terms of how to really get some training and really get folks, you know, who maybe had, had graduate school programs who are talking to them about contracting for safety and those sorts of things. Like, so, so much research, so much innovation has been done since a lot of us, myself included, have been in a grad school classroom that we know a lot differently about and how to treat that suicidality directly. So how can we really translate that into training for our staff? And so from this assessment, we decided to pilot like a small group of clinicians in one of our, it's a bigger location of ours, a clinical location, but we're going to do a suicide specific kind of specialty clinic. So just as, you know, if you go into the, your, your PCP and they decide, Hey, we might need to send you to a heart specialist. We're a little bit concerned about some arrhythmia with you going on. I'm kind of doing the same thing and saying a small group of clinicians who are going to get trained in several different evidence-based practices for suicide specific treatment modalities would, would be referred folks who are identified at high risk for suicide, especially coming out of a hospital. And so they'll get really focused care. And that's something that's going to, that's kind of our short slash longterm goal that we have in terms of making sure that we can get folks really trained up in terms of suicide specific evidence-based practices. We have a goal of the next three years to be able to do all of that. We're doing some implementation for new hires, but we'll start this fall and then we're going to try to go back and do some legacy staff here in the next, the two years after this first year. So three years total, but really what we've done with the suicide specialty clinic that's been really interesting. We have our chief psychology officers offering consultation with them weekly, and we have a small group of clinicians. There's three of them and over a six month period. So it's taking a little while of course, just because of the nature of behavioral mental health as a nonprofit, but over a six month course, they are receiving about 42 to 44 hours of suicide specific intervention training. They're using CAMS, dialectical behavioral skills therapy, CBT for suicide prevention. And then they're doing case studies. We have been able to reduce some of their workload. So a lot of them who would maybe do intakes are not doing intakes, but they're getting folks referred from an intake directly to them as they've been identified at high risk. And they've been able to have a little bit smaller caseloads, but because we're seeing those clients more frequently, some of those productivity things and kind of the business stuff that gets in the way sometimes, quite honestly, we've been able to sort of work around a little bit and they're receiving, we started doing this. We completed the care transitions assessment and action plan at the end of 2021. We really got the boots on the ground kind of an early 2022 and the staff there in that suicide specialty clinic have received all, I think it's 42 hours of suicide specific intervention training. It's 42 hours of training and they've started receiving referrals from the intake specialist to do some of this work. And we have an evaluation kind of arm to determine, you know, are they, are they showing to their appointments more frequently than maybe the general population? How has their improved mood? You know, we give them the CSSRS and the PHQ and do some other evaluation with them. So hopefully in a year or so we can come back in and talk about what, what kind of outcomes we have from that. And then in three years, I just can't wait. There's so many things that we want to do with this, but it really this care transitions planning really helped us kind of focus our effort and provide some of that structure to really make sure that again, not only is our responsibility to make sure that we grab that baton really securely from the inpatient facility and make sure that we've got a good hold on it, but what do we do once we have that full responsibility as well? And that, that to me really kind of encompasses all of that care, transition planning and all those sorts of things. So next slide. I think that was, was that it? Or was there one more? Okay. I'll pause here. And I think we're going to do maybe a combined Q and a Julie, I'm not sure. Yeah. First, before we move in, I, first of all, let me thank you, Megan. That was really, really interesting. You know, some of the things I thought were really eloquent were that you, how you do use data to drive why you're doing this. I was thinking you were talking about you know, you meet regularly with your QI team and you maybe have your risk management team at the table as well. Many of you, many of the participants clearly have risk managers and they're really important here in terms of using data to drive down readmissions, to drive down, you know, higher levels of care. And so all of that, that distinction of those who got these caring calls and contacts and follow-up services were more likely to go to their appointments, which are also about quality measures and HEDIS measures that have to be attended to. So I really think using data, you know, as opposed, right, there's sort of the ethical, it's the right thing to do, which also is why many of us went into this field. But I think using data to drive that point home is really important. So that was some of my key takeaways. Let's use this for a Q and A moment or for a moment in the Q and A for people to share their key takeaways, and then I'll open it up and look at some of the questions for both you and Jack. So let me know something that you, what was your key takeaway from what Megan just shared with us? I can see you like the phone calls for no-shows. It's a good summit, right? Somebody also talked about data, extensive training and evidence-based suicide prevention for a small clinician cohort, also using the data to measure outcomes. Other key takeaways that you are going to go back and share with your team immediately. Somebody talked about the big difference in sending a caring card to someone and then the actual follow-up or follow through that increases when doing this. And I don't know if people had seen some of that data or some of these examples in the past, but I think Megan's data shows that so clearly how this small gesture matters. And that's what, what the research shows. I think the training is critical. You know, a lot of the things in zero suicide certainly are the bundle of best practices, right? Do we do screening and risk assessment and safety planning and removing access to lethal means and treatment targeting somebody's thoughts of suicide and really coordinated, strong, caring contacts. But a lot of zero suicide is not only the what you do, but how you do it. It's not enough to just do each of those practices and say, okay, now we've got this effective bundle of interventions. It's really how you do it. And that includes training for the team. I, again, I think Megan mentioned this customer service emphasis and that people really need to know that, that they represent this tremendous opportunity for something for many families that has been very traumatic and scary, and they have the opportunity to reduce that. So lots of people commenting on the relay racing metaphor and the baton passing. And I, Megan, I think you'll let others use that if they want. I think it's such a wonderful metaphor, right? Like how's the baton supposed to get to the finish line? If the runners in the race, aren't really sensitive to holding it and ensuring that that care transition that time gets to the next runner. And frankly, they have nobody else to blame if they like just drop the baton in the middle. So I think it's a really apt analogy. But it also, it takes practice and coordination and communication. Again, people aren't winning those relay races without all of that. It's a team effort. So, all right, then Ebony, can you move us to the next slide? I want to move us on to questions. I want to first of all, thank both of our presenters, Megan and Jack, both shared really compelling examples that this is possible, right? That there are, that one, there's efforts that can be made that it is a journey that this is not just sort of embed a couple of practices and move on. It takes a lot of continuous coordination, practices and move on. It takes a lot of continuous quality improvement and training and evaluation of how well you're doing and then more CQI and more training. But it's doable and it not only is doable, but it's impactful. So thank you both. I'm going to look at some of our questions. All right. Somebody asked, do these best practices apply to patients with suicidal diagnoses who discharge from the emergency department to an inpatient medical hospital? Thoughts? I know I'm going to start with you, Jack. I know I don't think Megan runs at Centerstone and emergency department, but I welcome your, either of you, Megan or Jack, your experience. Sure. Can you ask that question one more time just to make sure I understand it? Do, if, would an emergency department use these best practices as well? Oh, okay, gotcha. So, absolutely. I mean, I think we've got a self-assessment tool, you know, that the National Action Alliance has provided. I think the least you can do is, you know, try it out, walk through that self-assessment as an organization and see where there are opportunities for, you know, things you could apply to your own care setting. I don't know exactly what that would look like when not, you know, a medical emergency department. Now, it wasn't patients that, you know, had a suicide risk or ideation, but I think, you know, walk through that self-assessment tool to go online and see what could apply. There's actually, and one of my colleagues, so there is some great research. It was the EDSAFE, S-A-F-E program. It was funded by NIMH several years ago that really looked at enhanced follow-up phone calls from discharging people from the emergency department and also found that doing this type of caring contact support was really supportive and helpful, and that, I can see your question, Jennifer. You were also asking, does this work from inpatient medical hospitals? And I think the answer is yes. We need to use the same, we can't silo suicide care to the mental health professionals, and in many cases, suicidal individuals aren't only seen there more or are frequently seen in emergency departments or inpatient medical systems, medical hospitals. These practices definitely do work. They need the same training and quality improvement and attention to doing them, right, as any other new initiative, but I think the idea of what is the care pathway and the care plan for people, say, in an inpatient medical system, a medical hospital with suicide risk, what is the care plan? Just as if you have a person who has asthma or a person receiving treatment for cancer, there are best practices that are implemented. There is a model for how that care pathway and the clinical workflow for who's gonna do the care, what needs to happen, you know, how do you ensure the baton isn't dropped, and that same care pathway needs to be in existence in every different type of healthcare setting and system. You didn't ask about primary care, but that's a completely appropriate setting for these care transitions as well. Somebody, Linda, oops, Linda is asking about suggestions for being included in the discharge planning for patients being sent home from, sent, I'm sorry, from an emergency department to inpatient treatment, even with a return on investment, even with the ROI sent with the patient, faxed to the inpatient hospital, I never got contacted, I'm sorry, different abbreviation for ROI, and faxed to the inpatient hospital, I never got contacted to help hand off care back to their home community. So I think what you're asking is how, and maybe either of you, again, Megan or Jack, I think you're really asking, Linda, for how is it that, you know, these things should happen, what do you do when they don't happen, even when you have systems in place, how do you strengthen that network between the emergency department and the inpatient setting, even if there are releases of information already in place, but something falls in the gaps. Megan or Jack, how about I'll start with you, Megan, because you probably get people from the ED all the time. Sure, and Jack, if you have anything to add, please do so from your expertise, but, you know, part of that is really that relationship building too, but being really honest in terms of, hey, we need this kind of communication feedback loop closed and it's not getting closed, and being able to express that to the folks that you need to express that to, and then again, say, here's what has happened, you know, we have this in place, but this didn't work, you know, we dropped the baton this time, here's maybe what I think we can do on our end to make sure that that doesn't happen again, but how can we help you on your end to make sure that that doesn't happen again either, and, you know, being friendly and maintaining that relationship, but I think being really open about here is an identified issue that we've come across and we really wanna work together with you all on the other end to make sure that that feedback loop gets closed, we have, you know, kind of an answer at the end because on our end, here's kind of what it feels like, it feels like maybe you just kind of send something off with ROI, and then you just never hear any information back again, here's kind of, we don't need much information, but here's what we would like to see happen after we do this, is that a possibility, or can we work towards making that become a possibility? Jack, what have you all done when you've noticed that some of the, despite having all the practices, policies, releases in place, it's still not super successful? Yeah, and so you're talking about releasing records? If you have records, releases of information in place already, so you know that you're allowed to, but the hospital, the emergency department, one transition to the other, they're never getting contacted to help hand off care back to somebody's home community, so like an emergency department, not speaking directly with the inpatient treatment team so that the inpatient treatment team doesn't really feel like they have all of the information to help the individual once they're gonna be discharged from inpatient care, because there's a little bit of a breakdown, like the emergency department lets the individual go, and then the baton isn't fully handed off. Of course, yeah, so I guess in my experience, what I'm hearing from this is, I think about this in terms of an intake and business development perspective, you know, we get a lot of patients from EDs that step up to an inpatient level of care, and so a big piece of that is making sure that there's a smooth conversation facilitated within the patient facts that the intake receives regarding patient's information and whether or not we can accept that referral, and business development plays a part in the service recovery side of things, but making sure that there's a really clear line of communication between all of our referral sources and community partners, with an open line of communication directly to the intake department. So in terms of making sure that the patient doesn't fall through the cracks if they show up to the ED and the services, it's all about communication and partnering with those community referral sources. Now, in terms of, I also think about this in terms of the patient discharging and having the next level provider that requires, you know, information to continue care. How can we make sure there's efficient communication about the patient's needs? And how can we connect the patient with that next level provider prior to them stepping down at the discharge? That's another part of the self-assessment tool that we've kind of discussed at our facility is how can we connect the patient with that next level provider prior to discharge, whether that's a therapist or, you know, some other facility. And so we've talked about innovative ways of, you know, having phone calls with the therapist prior to stepping down to understand, you know, what that treatment's going to look like, and things like that. So that's what it looks like for now. Thanks. Somebody else is asking, and I'll start with you then, Jack. How do you address the reluctance of parents or patients to reach out and give consent to exchanging information with schools? Oh, okay, gotcha. To consent to exchanging information with schools. And so, yeah, we've got a pretty large system of school-based partial hospitalization programming. So that is something that we're addressing in the past where, you know, teachers also want to be prompt to agree upon, you know, patients they've been referring to programs, how are they doing, three to four. And that's really a case-by-case discussion, you know, in terms of the family, in terms of evidence and information. We can't typically release what the patient's being treated for, and what other than the family, but I think the question is sharing information with the teachers, is that correct? I think just in general, as, you know, as kids in particular, and there were several questions about kids or going back to school, what if the parents or the youth say, I don't want you to talk to the school? Did you hear the question? I was having a little bit hard time. I'm gonna turn to you, Megan, just for the moment. So what do you do if a youth or their family says, this is like not my school's business, and I don't want you to share it with them? Yeah, I think, you know, on our end, we have some school-based programs here as well, but really kind of trying to emphasize the why behind we might wanna do that, you know, to give them the rationale for why this could be a good thing, more so than, you know, presenting it in a negative way of, well, if you don't do this, then this might happen. It's more of, here's how it can be really beneficial for your child, because it is a big transition to come back to school. And if he has, or she has maybe some assistance through a teacher or the guidance counselor, or what have you at the school, they're sort of an advocate for them while they're there, you know, eight hours a day, five days a week, as they're trying to make that transition back. And so we found that it could be really beneficial, maybe include an example of a real-world time where it was really helpful because you had the ROI for the school, and those sorts of things to really explain, here's really why we typically try to get this released for the school, and here's how it can be really beneficial for your kiddo when they go back, because it can be really, really difficult for them to go back, and there might be a lot of questions from other students, and a staff or faculty might be able to help them navigate that a little bit better, because you and I are not gonna be in school with them during that time, and kind of explain it to them that way. I think it's been really helpful for us, and we've been able to kind of explain, here's why we ask that this is signed, and help them kind of walk through that together. And I think the thing I would add to that, I mean, you know, I use a lot of comparisons that suicide care is no different in some ways than other medical care, right? If your kid is out of school because they just had heart surgery, or they're in getting kind of chemo for cancer treatment, or concussion protocol, or right, fill in the blank, we're very comfortable assuming that we're gonna share that information with the school, the people who need to know, things to look out for, here's our plan when, you know, my child will be coming or going, and I think we have to ask ourselves and our team when the family isn't so comfortable sharing that information, what is our own internal response? Is it to be like, yeah, yeah, it's okay, and to back off? Or is it to be really the educator about the importance of the need that it be part of a team effort, and here's why, and, you know, this is why we expect that this will happen as opposed to selling them or backing off because you get kind of bogged down in, you know, in biases. So I think that's a really critical change, and the more we can just normalize, got out of the hospital, or you're seeing a provider for some type of specialty care, the entire, you know, care continuum needs to be aware of it because that's just the way things are. Somebody asked, I thought this was a great question, do you utilize any adult or youth peer support staff to assist in transitions between levels of care or to help assist with reducing the AMAs that you were talking about, Jack? Do you guys use any peer supports to help in these conversations or to help when somebody is thinking about signing out AMA? So you're talking about like a peer support specialist, somebody that's had experience? We don't. We've discussed it, and I think that's a really great opportunity for us to look into. I think we have a lot of assistant facilities that do use peer support specialists or their substance use disorder programs. And so having somebody that has that experience that can conduct motivational care really is a really great idea and something we should look into. Yeah, we don't have a peer support in terms of like our hospital liaison program. We have some peer support specialist roles in some of our crisis, like our crisis call team has a few. And in our kind of larger zero suicide efforts in terms of what we do for follow-up care for those who we identify at high risk and enroll into our suicide prevention kind of clinical pathway model. And we have some designated folks who call and check in and kind of confirm means restriction, remind them of their appointments, ask them if they need anything while they're on the pathway who have some lived experience there, which has been really helpful. We found that it's been helpful for folks who maybe they don't have their own lived experience but have a close loved one who's been through suicide attempts and suicide ideation. That's been really helpful as well. So that kind of lived experience has also been really, really impactful for us. And I think it's something we can always improve upon. You know, those sorts of things I think can really be helpful. We have some group therapy treatments for suicidality where we see a lot of that kind of peer support within the group that's helpful as well. But yeah, I think there's always areas for improvement around peer support. And I think we have time for one more question. And I will toss this to you, Megan, first, which is how much support arose from institutional management spontaneously or did the clinical team and other stakeholders have to push for these business models around care transitions? And Robert, if you want to elaborate in the Q&A or box, then I'm happy to help elaborate on that question. But I think what you're asking is where do these models for better care transition supports, training, data, evaluation, you know, is that coming from leadership to say, here, I have a great idea, now do it, and here's all the money you need to get that done? Or is it clinical staff and other kind of people, other stakeholders on the ground who have had to bring this to leaders? I think for us, it's been a little bit of a mixture of both. A lot of it has come from boots on the ground workers where we have made it really clear and we've been able to really ensure that we do measure what we're doing and how well we're doing it so that we can always have evidence to support the need for either continued funding of this or additional funding and so on and so forth. We actually had the hospital liaison program was for a brief period of time, kind of in the early 2010s was pulled and we had data where we were using, you know, the hospital liaison model. We had data and then we were capturing data when we didn't have the funding to be able to show, hey, look at our engagement rates, look at the show rates, look at the recidivism. And we really pushed and got our own leadership involved to help them go to the state and say, we really would like to bring this back and here's how we've done it in the past and here's how well it worked. And right now we feel like this is a huge gap that's been created. So anywhere and everywhere you can, you know, collect the data, measure what you're doing and really be able to kind of show evidence of why something works and why you want to implement something if it's new as well. You can show them, hey, we know that we're struggling to get folks in and we know that maybe in Tennessee, this has worked well. Can we get this happening in our state, vice versa? Those sorts of things can be really impactful. And I've had the pleasure of working with both CenterStone and UHS for many years now. And so my observation is CenterStone has received, you know, sort of data then they received many grants to kind of embed new practices and then use that data to justify new hiring or moving people and shifting people's positions. Which then allowed them to be very creative and create these training modules and got new grants. So it's, but it's been, I mean, I've watched you guys go at this for, you know, we're hitting almost 10 years, right? So this is a journey. It wasn't overnight. What about you, Jack? How did this really get started at the Ridge? Yeah, well, I think two things. I'll first just paint a picture of how it worked when we got started with the initiative. We met on a monthly basis with the National Action Alliance and, you know, it facilitated conversations around the self-assessment tool. So the first regrouping of us as a leadership team with those Zooms, with the organization, we're centered around first what the results of the self-assessment tool looked like. And then on a periodic basis, we would regroup and say, this is what we're doing and this is what's working, what's not. Just as Megan said, measuring results, collecting data and showing, you know, improvement over time. So identifying, you know, opportunities for improvement, having those periodic discussions about progress and then just, you know, in terms of implementing change at the facility and having leadership support, I think it's important to note that a lot of this stuff actually makes business sense as well. So, you know, the step-down coordinator, for instance, retaining patients within our continuum, that makes business sense and it's good patient care to have that smooth transition to a quality outpatient program. Things like journey letters, retaining patients within our continuum, all these things, quality care makes good business sense as well. So they don't have to be separate. They're not exclusive of each other. And I think that's what I'll say is, you know, if you were to start with self-assessment tool, just collecting data and showing improvement over time, proving that it makes sense. I think that is a great way to end our webinar today. I'm gonna turn it over to you, Ebony, for these last couple of slides, but I really wanna thank our presenters, Megan and Jack, for sharing your journey with us and your expertise. I learned a lot and I really, it's a pleasure to get to hear and watch your journey and this wonderful work that you're doing. So these are a couple, this is the website that I mentioned at the beginning. And thank you. Ebony's gonna talk about CEUs and how to get the recording. Great. So thanks everyone for your presentations. I feel like we got a lot of great examples about how care transitions can be customized and still follow best practices for claiming credit for the webinar. You can follow the instructions here on the screen. And if there's any question that you might have about that, please email learningcenteratpsych.org and they'll respond with information to help you claim credit. Finally, I'd just like to thank the panelists again for sharing their time and expertise with us. And please also consider joining us for SBRC's next webinar on August 4th at 12 p.m. Eastern for a panel discussion with representatives of the Joint Commission on Suicide Prevention and Healthcare Accreditation. This concludes today's webinar session. Thank you. Bye-bye.

care transitions

suicide prevention

hospital liaison program

inpatient facilities

discharged clients

communication

collaboration

outpatient care

caring contacts

data measurement

residential treatment center

emergency departments

evidence-based practices