Good afternoon, everyone. Thank you so much for taking time out of your day to join us today. We're going to spend the next hour or so talking about suicide safer care, and particularly suicide prevention in primary care settings. So my name is Verna, and hopefully we can cover what you might have around questions and suicide safer care in primary care. There's a little bit of information here and a disclaimer from both SPRC and SAMHSA. So we're just going to take a moment so that you can get a chance to read both of these, and then we'll continue on. So I have no disclosures today, no financial relationships or conflicts that I need to report. A little bit about SPRC, for those of you who may not be familiar, the Suicide Prevention Resource Center is one of the only federally funded agencies devoted to advancing the implementation of the National Strategy for Suicide Prevention. So if any of you are not familiar with SPRC, I really encourage you to visit the website or to look them up. There's lots of information that you can get from them, and really helpful in terms of building capacity and infrastructure for organizations around suicide prevention nationally. So again, I thank them for their support in this effort, and certainly encourage you to go to the website, which is on the bottom left-hand corner, SPRC.org. Also letting you know that this activity is credited for CME credits, we'll be spending the designated amount of time. So we'll be giving you information on the CMEs. Okay, so now we're going to get started into the fun stuff today. I always like to start off and talk to everyone a little bit about language, because language matters and is so important. As we go through today, you'll hear me say died by suicide, as opposed to committed suicide. People commit crimes, and we know that we really want to try to use language that feels comfortable for people. So I encourage you to try to reframe and use died by suicide. And I know this is one that oftentimes people struggle with, because people have become so accustomed to using the words committed suicide or that phrase. Also encourage you to think about language around successful or unsuccessful attempts. I was in an emergency room one time working, and there was a 13-year-old that had tried to die by suicide that morning. And she was introduced to me by the emergency room physician. After so-and-so, she had an unsuccessful attempt this morning. So what that really meant is that we had someone, had they been successful, she wouldn't be with us, and that she couldn't die by suicide successfully. So really not messages that we want to send to individuals. Also behavior. Oftentimes I get the pleasure and privilege of going in and working with organizations and reviewing charts. And even in the electronic health records, I'll see language like patient was manipulative or patient attention seeking. And oftentimes it's in capital letters. And the other day I was looking at a record, and it was actually in the flag section of the chart so that when someone opened the chart, they actually saw patient is manipulative as a note for that patient. So oftentimes what we want to try to do is really put something in the chart that will be helpful to the other members of our team. And the way to do that is to really describe the behavior. What did someone do? What did someone say? Oftentimes I'll use quotes. That's going to be way more helpful to our other team members in terms of caring for that patient. And also I don't pretend to know what someone's intent is. I don't know about all of you, but I know many times in my life I've had to say, gosh, I'm really sorry. That just wasn't my intent, right? So I don't pretend to know someone's intent. What I do know is that someone who talks about suicide is more likely to die by suicide. And so I generally start there as opposed to pretending to know what their intent might be. And of course, using language that doesn't include dealing with, I prefer working with or perhaps even caring for. So really important to think about the language that we're using and really make sure that we're using language that feels comfortable for people. So what are we going to be talking about today? The role of the primary care provider in suicide safe care, identifying patients at risk for suicide assessment, some safety planning, and things that we can do during the course of a primary care visit, which I think is the most important thing. So why are we focusing on primary care and healthcare settings? Many of the people who die by suicide had a healthcare visit prior to their death. And many of them have actually seen a primary care provider during the month of death. One of the other pieces that we know and that we are starting to see is that patients who are disengaged from care, disengaged from primary care services, behavioral health services, actually resurface during the month of death for an average of two visits. And so this is really important information for primary care providers to know. Because if we know that many people who die by suicide saw their primary care provider in the month of death and that people resurface, then that really means an important place to catch individuals who may be at risk for suicide is in primary care. And I think many people are of the mind that unless we can engage primary care in efforts, we're not likely to see some of the changes in suicides nationally. So many organizations like the Joint Commission, CARF, and some of the others said to healthcare organization, hey guys, you really need to think about how you're caring for people at risk for suicide. What you're doing, you really need to have some systems in place so that you can have a process and a pathway in place to identify and care for people at risk for suicide. So certainly something to keep in mind. And also thinking about what some of the national patient safety goals are. If you're not familiar with these, we can certainly send them. The Joint Commission actually has a suicide prevention portal, which gives you some information and guidance so that you have it. It is really helpful, sort of ongoing and not just when you're preparing for a survey. So zero suicide is an incredibly helpful resource as well. And really sort of thinking about places where people can sort of fall through the cracks or the holes in your Swiss cheese, so to speak. And as an example, oftentimes we hear from healthcare organizations that there are places where they know people, they miss people or don't follow up with people at risk. So as an example, there was an organization in Montana and they had someone die by suicide and she had called and canceled the primary care appointment, canceled another type of appointment and then like a WIC kind of follow-up appointment. And one of the things that they realized is that nobody who picked up the phone knew that she was at risk for suicide. And there was no way for anyone to know that she had actually canceled three appointments in a short period of time. And so when you think about not having people fall through the cracks, is there some way as an example that people who are picking up the phone might know that somebody is at risk so that they can do something different. If people don't know, then they can't do something different. And so really encourage you to think about places where you might be able to change identifying and keeping someone who's at risk in care. So these are the seven elements of zero suicide. Many of you may be familiar with them. We're certainly going to touch on some of them today, particularly around identification and some treating and engaging. If you haven't been to the Zero Suicide website, I strongly encourage you to do so. It has some really cool information that you can do organizationally, has some really nice trainings and the ability to get some CME and CEU credits, particularly more advanced training around safety planning and using some of the tools that we're going to talk about today. So one of the things that we hear, and just to sort of do a little level setting, this project and this webinar is part of a larger initiative where we have gone around to 24 states now, either in person or certainly webinar over the past year in particular, and trained primary care providers in their teams. And we've trained well over 2000 primary care providers in their teams. And we've heard lots of really interesting things as we've had the opportunity to do that. One which didn't surprise me, but surprised others is that more than 90% of the primary care providers of all disciplines said, hey, I think this is part of my role, that suicide safer care is absolutely part of my role. We also learned that many of them, whether it was during their training or in their current organization, never had any formal training about how to care for patients at risk for suicide. So that's been a pretty interesting endeavor. And we heard some consistent themes. The first one that we often hear is, I don't know what to do, right? I don't have the knowledge to assess or intervene. And so one of the things that I always try to let people know is, you know, there's something that we know that saves lives and anyone on the primary team can do it regardless of their background or their licensure. And that's give someone hope. And I often ask people to think about a time when they told someone something and that first couple of seconds after they told them or that very first response from the other person really dictated whether or not you felt comfortable, whether or not you kept talking or sort of what happened next. And so when you think about someone telling you that they're thinking about suicide, perhaps even the first time that they've told someone, we really want to think about what do we want to relay to that person, right? What do we want them to know? And so I came up with a strategy some time ago when I was teaching social work students about caring for patients. And sometimes they would get a little rattled and they would lose their words. And so we came up with a concept called storage statements. And storage statements are things that we sort of store away that we think about ahead of time that we can use when we might need them when we're caught off guard. And so many times when someone tells us they're thinking about suicide, we get a little caught off guard. And so I really encourage you to think about what you might say to someone who has just told you that they're at risk for suicide. And so first I ask you to think about what would you like them to know? So the first thing that I think about that I want them to know is I heard you. I heard you tell me you were thinking about suicide. Thank you for telling me you're thinking about suicide. And we want to use the word suicide, right? So oftentimes people will say, well, thank you for telling me you're not feeling well, or thank you for telling me you're troubled. No, thank you for telling me you're thinking about suicide. The next thing I would want someone to know is that I cared about them, that they were important. So thank you for telling me you're thinking about suicide. Your life is very important to me. You're very important to us here at the center. And that we might want to give them hope. So thank you for telling me you're thinking about suicide. Your life is really important to me. I can see how strong you are. I know you've been through a lot and I can see the strength in you. So two to three sentences that we can say to someone who just disclosed to us, maybe even again for the first time that they're thinking about suicide. And so I encourage you maybe tonight when you're brushing your teeth to think about a storage, some storage statements, two or three sentences that you might say to someone who just told you they're thinking about suicide. And I had a provider in the Midwest and she sent me a message and she said, you know, Verna, when you were talking about storage statements, I was in the training and I kind of thought it was silly and I wasn't paying that much attention. And a couple days after your training, I had a patient and he said to me, I knew you were going to tell me this. I had a rope this morning, I should have hung myself. And she said, Verna, I didn't put any storage statements together, but I was really grateful that I remembered some of yours. And what I would like for you to do is to make sure that you share the story as you continue to do trainings so that people would take the time to maybe think about what their response might be ahead of time. The other thing that we often hear from providers and from teams in primary care as we go around is I just don't have the time, right? I don't have the time to ask about suicide risk. I don't have the time to address suicide. And I know working in primary care, I've spent literally my whole career working in health care and particularly primary care and community health centers. And I know how slammed primary care is all day, every day. And I really encourage you to think about how you identify and care for people at risk for suicide during the course of your regular primary care day. And one of the things that I often do when people tell me about time is to tell a little story which is actually a true story and my husband now knows that I tell it. So he unfortunately was hit by lightning and had some hearing loss. So we were going to the primary care provider for a follow-up and we went in, lovely medical assistant took his height and his weight and his temperature and his blood pressure and then left the room. And I thought to myself, that's a little, was a little rude. I'm an administrator and have worked in primary care and I thought, well, that was a little rude, but I had promised to be an observer in the car on the way there. So I didn't say anything. And a minute or two later, the primary care provider came in and she took his blood pressure. And she said to him, I'm really concerned about you. Your blood pressure is extremely high. And she asked him some questions about medication and had anything happened that day and a little bit about his history of high blood pressure or blood pressure. And then she said, listen, I'm going to go finish up with my other patients. And then I'm going to come back and we're going to talk some more. And she did, and we did. And so what I would encourage you to think about is that if he had said yes to suicide or whether his blood pressure was through the roof, the same thing happens. We stop, we get some information, we ask some clarifying questions and we come up with an appropriate level of care. This happens all day, every day in primary care. And in fact, it would be a beautiful day in primary care if people came in for what was actually the most primary presenting problem. And so we didn't talk about his hearing loss for the entire rest of that visit because it was no longer important. It was no longer front and center. And so primary care does this all day. They shift and pay attention to what's the most important. And so I encourage you to think about this, how you manage some other concerns that come up in primary care during the course of the day. Because what we want is we don't want people to panic, right? We want to be careful in terms of listening carefully and reflecting back, right? Your life is very important to me. I can see you've been through a lot and use our language and our storage statements. So when we think about identification, most primary care offices are screening patients for depression, particularly using the PHQ-2 and the PHQ-9. And so you already have a way where you're asking people directly about suicide. And we do know that patients who answer yes on question nine are in fact more likely to die by suicide. So oftentimes I have providers say, yeah, I get quite a few patients who answer yes to question nine. We want to make sure that we do have a process in place and that we're talking to them. And that we're asking patients directly what we want to know. So sometimes my patients who are struggling like you are think about suicide. I'm wondering if you're thinking about suicide today, right? That you're being very direct. Oftentimes social determinants play a role. We had a primary care provider who talked to us a little bit about a project that she had done and was in one of our trainings and had a patient who she said, we were really worried about this patient. He had a lot going on. And I called him, my team called him, we brought him in, I saw him, my team saw him. And he died by suicide last week. And when I think about it, he was absolutely at risk for suicide. He had some medical concerns and he wasn't able to work as much. They were having incredible financial problems. It had started to take a toll on his relationship. They were afraid they were going to lose their home. He had started to drink more than he should. And she said, now that I think back, we never once asked him about suicide. And so certainly the social determinants play a role, right? All of those pieces come into play and put someone at risk for suicide. Same with alcohol and substance abuse. Also transitions. Transitions are a huge time of risk for suicide. And oftentimes people think of just transitions as coming out of a medical hospitalization. But when we think about transition, we're really talking about coming out of any hospitalization, medical or psychiatric, substance abuse treatment, physical rehab, foster care. Any patient going through a transition is more at risk for suicide. And many organizations actually automatically ask people, particularly about suicide, even if they're redoing the PHQ-9 during times of transition so that they're asking people directly about suicide. And one of the things that I really encourage you to think about is your population of patients that are at risk for suicide. As we've been going around, I often ask organizations, so how many diabetics do you have? And oftentimes the answer is how many diabetics we have and our average A1Cs and this is what we're doing and we have this registry. And then I say, well, how many patients do you have at risk for suicide? And I would say about maybe five-ish organizations have actually been able to answer that question. And so one of the things that I encourage you to do is to start adding the code, the suicide codes to the problem list. So we're fortunate to live in a world where there's a code for everything. So right now I'm sitting in South Carolina and if I went outside and a bat fell on my head, there is a code for that. And so there are codes for suicide risk. Put them on your problem list because what it automatically does is then give you structured data to be able to track your populations at risk. It doesn't cost you anything, you can do it right away. It's already built into your EMR. The other thing that this does is that if I'm covering for you and I take call and you're a primary care provider and I see suicide risk on the problem list, I may do something differently or make some different decisions or ask if someone is safe. So it's really, really important information to have. And a lot of times people will say, well, I don't know if my patients would want suicide risk on the problem list. And what I say is that if you let people know, thank you for telling me that you're thinking about suicide today. You're really important to me and I just wanna let you know that I've put the information on your suicidal thoughts in your chart because I wanna make sure that every time I talk to you or someone from my team talks to you, we make sure you're safe. And I've never once had a patient say that they didn't want that information in their record. I would also encourage you to think about two populations. The first one and the one we often think about most is the patients we've just identified. So when someone gets identified as being at risk for suicide, often organizations have a process in place, right? This is what we do, regardless of what it is, but oftentimes there's no process in place for when people come back for care. So as an example, I was looking at records in a school-based health center and there was an adolescent male who came in to get some forms filled out. And he answered yes to thinking about suicide. And there was a lot of commotion and people asked him questions and there was documentation and I think they even sent him out. And then he came back three weeks later to get those same forms filled out, saw a different provider and no one asked him about the suicide risk. No one asked him if he was safe. It was as if it never happened. It was never on the problem list. And so really encouraging you to think about what is the expectation when somebody comes back for primary care, what do you expect to happen at the very minimum? So if somebody comes in for asthma, you automatically have some processes in place. You ask them if they've used their emergency medication, have they been to the emergency room? Do they have their asthma action plan? And so really encouraging you to think about what do you wanna know for patients coming back from care and what questions could you ask them? And really thinking about what does excellent care for patients at risk for suicide in your organization look like? And we talked a little bit about depression screening and all of you are probably familiar with this tool, the PHQ-9. And one of the things that I often like to do is whether it's on the computer or paper is to really review the PHQ-9 with patients after they've completed it before they have their primary care visit and to go over it and to say to someone, so I see that you're having trouble falling asleep and staying asleep and that's a problem for you nearly every day and that you're feeling tired and having little energy and that's a problem for you more than half of the days and that you're having some trouble concentrating on things like the newspaper or TV and that's a problem for you nearly every day. So it sounds like you're really having difficulty sleeping and some of those other things that you described and that you checked here are related. And I really wanna make sure that we spend some time and have some conversations and we can try to help you with your sleeping. I also see that you have thoughts that you would be better off dead or hurting yourself in some way and that's a problem for you more than half the days. So thank you for telling me that you're thinking about suicide. You're really important to me. What I'd like to do is to just start with your thoughts about suicide and ask you some additional questions. And so really making sure that you just transition then to asking someone about their suicide risk. And so that's gonna be really important. And so one of the things, so there's a question in about a patient that told me she put a noose around her neck three months ago but decided not to because she did not wanna hurt herself. So I would actually put that under an attempt and certainly would address it with that patient as such. So thank you for some of you that are putting questions and I'm trying to answer them a little bit as we go along. Oops. So this is the PHQA for adolescents. Sometimes organizations or providers aren't familiar with having a PHQA. I also do mention the ASQ here. The ASQ is really helpful, particularly for children. Unfortunately, what we're seeing is that suicide is one of the top leading causes of death in 10 to 14 year olds. I never thought that I would use the words pediatric and suicide in the same sentence as much as I do these days. It still pains me a little bit every time that I say it. So certainly the ASQ is a screening tool that it is worth looking at. One of the nice things about the ASQ is that it does have a handout or a guide that you can give for both nursing staff in your practices as well as parents or guardians. You can actually go on the National Institute of Mental Health, NIMH, and search the ASQ and there's an entire toolkit there that you're able to use. So if you have a pediatric population then I encourage you to really look this. I think it might be incredibly helpful for you. And so thinking about now we've just talked about screening people and using some of the PHQ as an example or the PHQA and having folks that identify as yes, I'm thinking about, I'm having thoughts of suicide or thinking that I would be better off dead or hurting myself in some way. And so now really thinking about what could happen next. And so one of the things that I will sometimes hear from primary care providers and certainly from patients is then I was immediately sent to the emergency room or emergency services were called. And so what I encourage you to think about is an appropriate level of care for everyone. We know that sending some patients to the emergency room who don't need to be there, that it can actually make things worse for them. And so what we always wanna do is make sure to the best of our ability that we're making an appropriate plan of care for everybody in our care. And so as an example, if you think about just going back to our asthmatics again, if someone comes in and they're having an asthma attack, then what you might often do is give them a treatment, get some information from them, maybe do some education around using their inhaler or a spacer, you might change a medication, you might redo an asthma action plan, you might talk to them about triggers in their environment or emotional triggers, and then you would come up with an appropriate level of care. And so really doing the same with people at risk for suicide. And so if we send everybody who was having an asthma attack to the emergency room, then what would happen is people would say, well, I don't need to go there, they're just gonna send me to the emergency room, so I'll just go right to the emergency room. And we certainly don't want that and our friends in the emergency room probably wouldn't want that either. Or you know what, I don't wanna go to the emergency room, I don't need to go to the emergency room, and so I'll just stay home. And then we have people at risk for suicide or with asthma staying home, which is not what we want either. So really important to think about what appropriate levels of care are for everyone, because not everybody needs an alternate level of care. And I've worked in an emergency room for more than 17 years on the behavioral health team. I can certainly tell you there's no magic that happens in emergency rooms. And oftentimes, I would be perplexed why patients were sent to me from places where they were known and people could certainly get some information and do some safety planning with them. So when we think about assessing risk, it absolutely happens in primary care settings. Primary care settings and primary care providers assess people for risk all the time, right? And so it's really helpful then to have it become the focus of the primary care visit. And so in front of you, you see a tool called the Columbia Scale or the CSSRS. We affectionately call this the primary care version. And that's because this really is helpful for primary care to be able to determine appropriate levels of care. And so oftentimes, if somebody says that they're at risk for suicide, we ask them a couple of questions. And what's nice about this Columbia Scale is that it's only six questions and I really encourage everyone to ask all six. And it gives you a structured evidence-based way to ask people about their thoughts about suicide. And in particular, to ask about intent. Because one of the things that we know is that I can be thinking about suicide. I can know how I might die by suicide, but do I intend to die by suicide? That really contributes to my imminent risk. And so if you look at the questions, have you had these thoughts or had some intention of acting on them? As opposed to, I have the thoughts, but I definitely would not do anything about them. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? So we're gonna talk about what you will be able to do during the course of a routine primary care visit for patients who are yellow and orange. And then patients who are red who say, yeah, I actually do intend to carry out my plan. I would do something about the thoughts that I'm having. Are folks that likely need another set of eyes and maybe need an alternative level of care. And so certainly again, the intent. Have you had some intention of acting on these thoughts? So also when we think about risk, we think about protective factors. So what are some of the reasons you would not die by suicide today? So certainly we hear my kids, right? And I'll reinforce absolutely your children really need their mom. Family, spouses or parents, pets. I had a woman tell me not that long ago, she had a pit bull and she said, you know what? If I give him away or put him back in the shelter, nobody will adopt him. He may get put to sleep, right? That was her reason for living. Religion or a job. So if someone has more protective factors and less intent versus somebody who has few protective factors and more intent, those are the folks then who are at more risk. And so next to talk about safety planning. Safety planning is actually an intervention that has been shown to be helpful for people who are at risk for suicide. We used to do something called contracting for safety. We now know that contracting for safety is not helpful and is in fact dangerous. And so we don't do contracting for safety any longer. So what do we want you to do at a very minimum? Is we wanna make sure that you're giving patients the lifeline number. And what we wanna do is I often tell them, pull out your phone and I have them program the number right in. I know we used to have the little cards and then nobody could ever find the card when they needed it. And I know for me, if you give me a little card, the likelihood that I'm gonna have it or know where it is 30 minutes later is pretty thin. So I have patients call, pull out their phone, put the number in, text, put the text in and actually send a text. Because then what we know is they have that information where they need it, when they need it. And oftentimes you can say to someone, why don't you give them a call? I'm gonna step out and go see another patient. Why don't you give them a call? I also give them another evidence-based intervention, which is the Now Matters Now website. It's been shown to help people that are at risk for suicide. It's again, available 24 hours a day. I'll often have them pull it up on their phone or our computer in the office. So now you've given them two things that they can have at their fingertips that have been shown to be helpful for people who are at risk for suicide. I will also give the Suicide is Different website, particularly for parents or family members. Oftentimes they find it helpful and it can give them some support. And again, talking a little bit about safety planning and thinking about risk. So as an example, you often will see, and you can see it actually on the Now Matters Now website, and sort of a correlation between suicide prevention information and fire safety information. And so we know that risk can change. And if we were all in a room right now, and maybe someday all of us will get to be in a room again together, and I asked everyone in the room and said, so tell me a little bit, if you were to catch on fire, you know, when you were young and you were taught what to do if you caught on fire, what were you taught to do? Every one of you would probably say stop, drop, and roll. So even though the likelihood that we would catch on physical fire is pretty low, all of us were taught to stop, drop, and roll. Well, I like to teach people what to do if they catch on emotional fire, even though the likelihood that they might catch on emotional fire is low. And if you think about it, the same things are helpful. If I stop, drop, and roll, I'm not dying by suicide. It's really important to stop that repetitive thinking, right, to shut those thoughts down. And so if I splash cold water on myself, if I make eye contact with someone, that's really gonna help me if I'm on emotional fire. And so I let people know that I want them to know what to do if they catch on emotional fire, like they know what to do if they catch on physical fire. And oftentimes, that's tremendously helpful for people to really think about what to do. Because if you think about it, if you're on physical fire, you often can't call 911, right? You have to do something to be able to then do that. And so if you're on emotional fire, you have to shut the thoughts down so that you can do something else that might be on your safety plan. And if you go to the Now Matters Now website, this information is actually on there. And there's a little plan that you can print out for patients that I often will give them. So this is a safety plan and a safety plan template. Again, safety plans are evidence-based, and they are shown to be helpful for people who are at risk for suicide. And as we've been traveling around, one of the things that I've been struck by is how many people on the healthcare team were really interested in helping patients with safety plans, particularly the nursing staff and nursing teams. So many places, the nursing teams came up to us and said, hey, spend some extra time, really show us how to do safety plans. If you want, again, on the Zero Suicide website, you can get some additional information. So the thing about safety plans is that it's really important to get information that's very personal for that patient. So the first thing we wanna do is we wanna maybe get some information about people who can be helpful for them. And what we wanna do is we wanna call them, right? So we wanna say, hey, you know, Adam, Verna said you were someone that she would like to have on her safety plan in case she's thinking about suicide. And then Adam has the opportunity to say, hey, that would be really cool, but it's really scary for me, I'm not really sure I know what to do. And maybe we could give him the Suicide is Different website, or Verna could say, you know, hey, listen, I just need you to pick up the phone and be there for me, right? Or maybe Adam says, you know what, I would love to, but I'm teaching webinars all day, and I'm not able to always pick up my phone. And so then we can say, if Adam's not able to pick up his phone, maybe you could call the lifeline so that there's some backup. Or maybe Adam says, you know what, I don't wanna be a part of the safety plan, and then we can come up with some alternative. So it's really helpful to be able to talk to people that the person would want on their safety plan. And then also to think about activities. And oftentimes I'm looking at safety plans, and I see patient will go for a walk. And so we wanna make sure that we're really specific. Where would I walk? What street? What area? What would I see? Why would I choose to take that walk? What would I see? What would be helpful for me? Music, what music? What music would I listen to? I had someone tell me not that long ago, she had a playlist on Spotify. It was called the Suicide Playlist. I probably would have picked a different name. But we actually listened to it, and I say, why did you pick some of these songs? You know, and she talked to me about what songs and why they were significant for her and how many songs were on there. And so we were able to really put that playlist on her safety plan. It was something really personal for her and very specific. I also wanna make sure that if something is on a safety plan and activity, I always say a good rule of thumb is to think about, is that an activity that's not only very personal for that person, but is it something that could be done at all times of the day or all times of the year? So I was working with a woman and she lived in an area of the country where it gets incredibly cold. And she unfortunately lost many members of her family, was feeling very sad and alone, struggling with suicide. And what she liked to do was to go into the town and there was a daycare center there, walking distance from her home. And she liked to sit by the center and watch the kids. And one of the things that we talked about was, well, that's not something you can do in the middle of the night, or that's not something that you can do in January or if the weather's bad, or there are times when the children aren't gonna be outside. So what other things might you be able to do, right? Or if it's take a walk, there are some neighborhoods where it maybe is not safe to walk at two o'clock in the morning, or if the weather is bad, right? So are there things that you might be able to do all times of the day or all times of the year? And if not, then what sort of a backup activity, right? So if we're not able to go outside or do an activity, what could we do instead so that we have a plan? So again, can that activity happen at all times of the day and all times of the year? And often really be creative. So tell me about places in your community that are open every day or all hours of the day. I often hear Walmart because Walmart is in many communities. It's accessible by public transportation. It's open 24 hours a day. And ask, how can we keep you safe today? What are some thoughts you have about being safe? And really eliciting from people, because people have thought about how to be safe. So I ask them, what are some thoughts that you have about being safe today? How can we keep you safe today? What would it look like? And also to talk to people about lethal means. There is a wonderful section and training on the Zero Suicide website about lethal means restriction. It's really important to know about lethal means restriction. One important piece is that we have learned that oftentimes people don't change. So if I'm thinking about suicide and I'm thinking about using a firearm and we can keep me safe and I don't have access to that firearm, then oftentimes we have been able to keep me safe. And so we wanna try to talk to patients about lethal means and lethal means restriction. And it's really important to note that information so you know it, people on your team know it. And then when you talk to patients, make it part of standard practice. So I talk to all of my patients who talk to me about suicide, about being safe, and particularly making sure that they don't have access to their gun. So letting people know that it's temporary, this doesn't mean that you can never have your gun or that you won't be able to go hunting in the fall or that you won't be able to drive again. So really making sure that people know, hey, I talked to all of my patients about being safe. This is something that we do. And letting them know that it's temporary so that you can make sure that it's covered and that you do that and that you note it in the chart as well so that it's important to be able to see all of that information. So oftentimes I'll ask people, so many times we worry about the medications that we're prescribing people. And I'll ask people, how much medication is in your home? Or you talk to me about your thoughts of suicide and that you would use medications, where would you get the medications? And oftentimes people will say, well, when my aunt died, my grandmother kept all of her medications. Like we have bags full in the house, right? Now is the time to sort of think about talking to your pharmacy and things that they might be able to do. I really like the Amazon pill packs, not only because it helps me remember to take my medications, but also for patients at risk for suicide because they come in those individual pill packs. And we know that individually wrapped pills or medications is really helpful for people at risk for suicide because I'm at much less risk if I have to open each of those packets. And also to think about gun locks or boxes, right? So in other words, are there family members? Does a family member need to get a permit to be able to have a firearm so that they could hold a firearm if needed? So sometimes it really means getting gun locks or boxes. Using family pictures or photographs and putting them on boxes, gun locks, or gun cabinets is often helpful. And again, try to think about some of those pieces now. Do you have gun locks that you can give out to patients? Do you have a pharmacy partner that will give less prescriptions for a patient or will help you with pill boxes or individual wrapping for medication so that you have all that ahead of time and that you've really had an opportunity to think about it? And those are sort of really important pieces to be able to think about as you're going along. And when you think about a primary care visit and what generally happens during a primary care visit and somebody coming in and your ability to ask them questions, particularly with screening, and now we're screening patients for, we're all experting for substance use, we're asking about family violence, we're asking about social determinants of health. So the ability to ask patients about suicide to get and identify people who may be at risk, have some language that we can use when we identify them so that we're able to then talk to them, get some additional information from them, go into a tool like the Columbia Scale. And I've done Columbia Scales, I've done asthma action plans, and certainly both fit very nicely into a primary care workflow. So I'm asking my Columbia Scale, talking to someone about intent and then giving them some information that will keep them safe. So like we would with other chronic illnesses, giving them some information to be able to keep them safe. So in other words, here's an action plan or a safety plan, here's some information, let's talk a little bit about some resources, right? We often give patients resources in primary care, information that they can follow up on on different chronic illnesses or different medications or different treatments. So here's some information, someone that you can call in case you're not feeling well or you're not feeling safe. Here's the lifeline, let's make sure to put it in your phone. Here's additional information around a website that you would be able to visit. Here's some information in case you're in crisis and you're on emotional fire. Let's talk a little bit or some things that you might be able to do. So oftentimes with chronic illnesses, we give patients some activities or things that they might be able to do that would be helpful for them. So maybe it's taking a walk or some increased physical activity or talking to them about their diet or diet restrictions. And so in the case of someone at risk for suicide, we're talking to them about safety planning, some activities that they could do, some people that they could call. So when you think about what you do now for chronic illness and what you do for patients who are coming in with chronic illnesses, many of the same workflows, many of the same processes that you follow, you can follow for someone at risk for suicide. You have the language, you have the resources, you have the information. And so oftentimes when you have that, it really folds into what can happen during the course of a primary care visit. And if you have a process and you have your team all prepared, then certainly it makes caring for patients at risk for suicide in primary care much easier. And then also thinking about what happens when people come back for follow-up visits. And so I one time worked in an organization and I had this really bright idea that I was gonna turn the electronic health record banner red for patients who were at risk for suicide. And what I saw is that it didn't really change what happened in a visit. And I realized that was really my fault because we had never really clarified what we expected to happen in that follow-up visit. And so I encourage you to think about because even if someone is referred out and is getting the best behavioral health care, they're gonna come back for their primary care. And so what do you wanna know? You wanna make sure that you're asking them whether or not they're safe. Do you have a copy of your safety plan? Has anything changed on your safety plan, right? That you're doing that and that you're making sure that people are safe. And so when we think about what else we might be able to do to support patients, one of the things that has come up is the ability to do what's called caring contacts. And oftentimes primary care organizations will send a caring contact to someone after they've seen them for the first time and maybe they've identified that they're at risk for suicide. And so they came actually out of Australia where people would go into the Outback and they knew that they weren't gonna see them again and they would send a little note that says, hey, thinking about you, hope you're well. And what they found is that that actually reduced suicides. And so what I have often done is encourage primary care providers to just send a little note the first time that they see a patient or a patient discloses they're at risk. And again, it really comes to back to helping to support that patient. So I know that when I worked in the emergency room and I was sending someone home, I would write a little note on my clipboard and I would say, hey, hope this note finds you well. I'm really glad we had an opportunity to meet Verna. And I would pop it in the mail basket before I left for the night. And I worked in a community where the likelihood that you would run into someone that you cared for was pretty high. And I was in the grocery store with my daughter and this woman came up to me and I didn't recognize her at first. And she pulled the note out of her purse. And she said to me, thank you for sending this to me. I carry it with me, it's helpful. And just having that note with her really gave her hope. And so really encouraging you to think about how you can impact people at risk for suicide with your storage statements, giving people hope and following up with them as they come back into care and sending them caring contacts. So I wanna thank you. I know we have a couple of questions in the chat. And here's some examples of caring contacts. So I know that when patients are at risk caring messages can help. So some examples of caring messages. So someone asked about the template. Again, it's the NIMH website, the National Institute for Mental Health is for the ASQ. And then also you can go to the Zero Suicide website for other information. And of course, Now Matters Now, which has some information on the risk safety planning and also is really helpful for patients. They also do have a section on that website for clinicians. So why is contracting for safety not done anymore? Because essentially what we don't wanna do is have people promise that they're not gonna die by suicide that's really more about us versus what might be helpful for them and keeping them safe. So there's quite a bit out there in the literature looking at contracting for safety versus what you can do around safety planning. I'm just trying to go through and make sure we've covered some of the questions. Okay. So there's a question in here about notifying the parents. So some of the pieces really depend on what kind of setting you're in. It also depends on the age. So certainly many of the adolescents who say that they maybe are thinking about suicide can have a safety plan. We can engage some people that might be supportive. So I had someone the other day and we did a safety plan and we engaged another relative in her care and she was amenable to sort of having her on her safety plan so I think it really depends on the situation and your setting. Okay. So safety planning is actually what we wanna do. We want to, the field has moved away from contracting for safety. So safety planning is an evidence-based best practice and so we definitely wanna do safety plans with people. Can we have access to the patient safety plan to use with our patients? Yes, absolutely. On the Zero Suicide website, you'll actually see the safety plan that I had up here and you can get it. It's the Stanley and Brown safety plan. If you Google it, it's also out there. So that is incredibly helpful. Someone asked about the ASQ. So yes, the ASQ has a lot of research behind it. That research and that information is actually on the NIMH website. I like the ASQ. I think it's short. It's good for all ages. So certainly a tool if you're not familiar with it, it is not built into the electronic health records like the Columbia scale or the CSSRS is, but I certainly think looking at both tools and thinking about what ages you're caring for might be helpful. So what's nice about the CSSRS, particularly the version that I showed was that it's helpful when you're doing workflows or pathways to use the color coding in terms of thinking about what some responses could be. So I think certainly familiarity with both tools is often helpful. So when we think about legal considerations, so a couple of questions have come in. How does this work with virtual and telehealth situations as well as legal? So one of the pieces is that, sending someone to the emergency room doesn't sort of change the liability as much as primary care organizations sometimes think that it does. It's really about making sure that you have processes in place with evidence-based tools and interventions and you follow them each time. So that's gonna be really important and clear and is also documenting what your thought process is. But if you have a pathway and each time you ask the PHQ and then you use the Columbia scale and you have safety plans built in and you have a process and you put suicide risk on the problem list, then you're really taking some great steps. So when we think about virtual care or telehealth, I think certainly there are some considerations now that we're doing a lot of telephonic work. I will often ask patients in the beginning, so where are you, right? Where are you located? Are you home? Are you somewhere in the community? Because now oftentimes we have patients where there's a lot of people home because of COVID. And so oftentimes, they can get a little peace by being outside. So I often will ask them where they are. So those might be some special considerations that you might have to have. Okay, everyone. Well, thank you so much. We appreciate your time and please enjoy the rest of your day. Thank you.

suicide prevention

primary care settings

reduce stigma

identify patients at risk

safety planning

coping with distress

supportive individuals

managing emotional distress

caring contacts

technology for suicide prevention