 So, I would like to transition us to our first panel of the day, Exploring Care System Solutions, which I think is going to follow very nicely from Dr. Franklin's presentation. So I would like to first introduce our moderator for this panel, Dr. Julie Goldstein-Gromit. She is the director of the Zero Suicide Institute, which provides expert consultation and guidance to health and behavioral health care organizations implementing the Zero Suicide Framework for Safer Suicide Care. She's the director of health and behavioral health initiatives for Suicide Prevention Resource Center, a federally funded resource center devoted to advancing the U.S. national strategy, which we saw for suicide prevention. And Zero Suicide Institute and SPRC are part of the Education Development Center, a global nonprofit that advances lasting solutions to improve education, promote health, and expand economic opportunity. She has her doctorate in clinical psychology from GW and completed a postdoctoral fellowship in school mental health at the University of Maryland School of Medicine Center for Mental Health Assistance. So welcome Julie. I'll ask you to introduce your panel. Thank you. So good morning. I'm Julie Goldstein-Gromit. It's really a pleasure to be here and be your first panel. I was going to introduce each of our panelists, I think, in turn, unless you want me to introduce them. I was going to introduce each of them in turn, I think, after I give you a little bit of background about setting the stage for what our panel is. And the goal of our panel is to describe the current research that exists about what actions health care systems can take to prevent suicide. We know that 45 percent of people who died by suicide have seen a primary care provider within a month of their death. So we know people are touching the health care system and that health care plays a critical role in suicide prevention. And we hope to share innovative solutions with you today that you can take home with you. I'm your moderator and I'm going to tell you a little bit about both the Suicide Prevention Resource Center and Zero Suicide. So next slide. The Suicide Prevention Resource Center is funded by SAMHSA, the Substance Abuse Mental Health Services Administration. We're a clearinghouse of resources. We have a lot of resources for health care providers. In particular, a course called COM, Counseling on Access to Lethal Means. It's a free course. We've already begun to hear a little bit about the role that reducing access to lethal means plays in reducing one's risk for suicide. But sometimes people don't know what to do. What does that mean? How do you have that conversation? It's a very delicate conversation all across the country. How do you have that conversation in a meaningful way to ensure that you've been able to reduce somebody's access? So there's a free course called COM. There's also a comprehensive approach for effective prevention in the community. What we're going to talk about is really the kind of evidence-based practices that work in health care. But there is a comprehensive approach for the community of which the health care system needs to be a part. But we also need to think about the faith community, upstream schools. What is your data say about where to begin in your community? Veterans and many other different overlapping risk and protective factors that need to be a part of your approach. So I also encourage everybody, if you don't already know who your state suicide prevention coordinator is, you can find them on the SPRC website. I think we often work in silos. Health care works alone. The community works alone. Substance use, even though they might be looking at the intersection works alone. The more we can band together with our combined resources, training opportunities, as you know, it's all the same shared risk factors. So reach out to your state suicide prevention coordinator. And if you go to the button on the far right that said organizations and drop that menu and look up states, you'll be able to find your coordinator. The SPRC website is at the top at sprc.org. Everything on that website is free. And we're constantly including information. There's also a weekly newsletter that people can sign up to receive. Next slide. So under the umbrella of EDC and the Suicide Prevention Resource Center is also the National Action Alliance. And in 2012, the US Surgeon General and the Action Alliance updated the national strategy for suicide prevention, including goals eight and nine, which was the first time, even though there had been a national strategy in 2002, in 2002, health care was not included as specific goals or settings to reduce suicide in this country. And that seems so surprising, knowing what we know now. But I think the assumption was that the health care community's got it. You got about a licensed psychologist, social workers, psychiatry, they know what to do, they've got good protocols in place. So it was really about the community doing awareness, raising, maybe identifying people and then getting them to the health care system. And then people would be safe. And in part, that's true. And people do amazing work in the health care system. But without really drawing out, health care is a very specific place to really embed best practices, evidence-based approaches. We're not going to really do anything to tip the needle in terms of suicides in this country. And we also know that health care system leaders who've really kind of questioned the myth. I mean, I think the other, the flip of that is a lot of health care system leaders and people who work in health care. While there are amazing individuals, I do think there's sort of an underlying myth that if somebody wants to die by suicide, then they will. And that when you work in health care, suicide is inevitable. I think those are myths. And we know that evidence-based practices absolutely work to reduce suicide in this country. I think those myths are really beginning to go away. I think we've absolutely, but really only in the last, maybe like six years or so, I think that's a, as I've begun to talk to CEOs and health care leaders about the adoption of zero suicide, there's an inherent tension sometimes about can we are seeing the people at 20 times higher risk than the general population? Can we really reduce suicide in this population? And I think that's what zero suicide is about is that we have to do more. There are best practices that work that people in health care are not currently using and we can, they're available and we have to do more. Next slide. So I'm going to show you a brief video about zero suicide. Every minute of every day, suicide impacts the lives of hundreds of people across the globe. It robs families of loved ones, young people of their future, workplaces of colleagues and communities of their most valuable resource, their people. And surprisingly, of the 800,000 people a year worldwide who die of suicide, most saw a health care professional in the year prior to their death. Contrary to popular belief, the problem isn't that those at risk are disconnected from health care. It's that gaps exist that allow these individuals to slip through. Despite this, health care has remained unchanged, presuming many deaths were tragically inevitable. Inspired by the Henry Ford Health System in Detroit, zero suicide is a call to action based on the belief that no suicide is faded. It all starts with zero because a radical and systematic approach to perfection is the only way to create dramatic change. And it must be driven by leadership's commitment to creating a new culture around suicide prevention. Three specific evidence-based interventions have emerged as central to zero suicide, creating the multilayered approach that helps ensure no one slips through the cracks. First, we must make it okay to talk about suicide. Health care must routinely screen for suicide risk at all patient touch points within a health system. Simple screening questions like, do you have thoughts that you'd be better off dead or hurting yourself? Allows health care professionals to start a conversation about suicide, create a connection and acknowledge the anguish and pain. The simple act of asking about suicide risk is more predictive of a future suicide attempt than even cholesterol scores are for a future heart attack. Second, the strongest resource in preventing suicide is always the person at risk by collaboratively designing safety crisis plans that include reducing access to lethal means and following up with phone calls after discharge, one recent study showed a 45% reduction in suicidal behavior. And third, we must treat suicide directly. We've assumed that treating mental health and or addiction will fix suicide risk, but that doesn't always remedy the pain that underlie thoughts of suicide. Zero suicide trains health professionals to deliver specific treatment, as well as caring and supportive contacts either between appointments or as post-care follow-up in the weeks and months to come. This relentless pursuit of perfection and insistence on evidence-based intervention works. Henry Ford saw a dramatic 80% reduction in suicide and maintained that success over a decade, including one year when they actually achieved zero. And at Nashville-based Centerstone, one of the largest nonprofit community mental health programs in the U.S., they reported a 64% reduction in suicide deaths since implementing these initiatives. And on the other side of the world, Gold Coast Health in Queensland has exceeded by utilizing the resources of the Suicide Prevention Resource Center, including a specific toolkit with a set of practices and resources for data collection and continuous quality improvement. Additionally, thousands of other organizations around the world are now taking their first steps towards zero suicide. Bold visions have put a man on the moon and cured polio. For suicide prevention, there's no more time for half-measures and missed opportunities. Only with insightful leadership committed to the pursuit of zero suicide, will we be able to make significant strides towards eradicating these tragedies. Zero suicide, healthcare that believes no one should die alone and to despair. Okay, next slide. I do think that you're getting resources after today sent out potentially and I'll include the link to the video and people can watch it. It's really just kind of sets the framework for how do people fall in the gaps in healthcare systems currently. But these are the seven elements of zero suicide. Leadership that has a culture change committed to reducing suicide, training of everybody who works in the workforce so that people are competent to use the skills, not just to give them the tools but to tell them how to use those tools. Identifying people at risk through standardized screening tools and risk assessment. Engaging people using a very robust suicide care management plan. In healthcare, we have care management for asthma, chronic heart disease. We need to have the same thing in behavioral health for suicide care, including safety planning and lethal means. We have to treat the suicidal thoughts directly. There's dialectical behavior therapy, CAMS, cognitive therapy for suicide prevention. There are treatments at work. But again, we often treat around the suicide. We'll treat the anxiety and hope the suicide goes away or treat the substance use and hope the suicide goes away. We can treat and target suicide behaviors directly. We have to transition people. Keita talked a little bit about the use of caring contacts. We have to support people in that transition. Imagine being newly diagnosed with depression, having the first time thoughts of suicide and being told to go see a mental health provider and you or your family are thinking, I don't even know what that is. I've already been in a hospital for a week. I've missed time. I don't know how to explain this to my colleagues. I'm better now. We have to be able to support people through these times of transition and our colleagues on the panel today are gonna go into more detail. And everything that we do, we have to use continuous quality improvement. We have to say, if we're doing it, are we doing it with fidelity and what is our data telling us about how well we're doing? Next slide. Zero Suicide's an aspirational goal. I was a state coordinator for a while in DC for suicide. And when you write your plan, you say, we're gonna reduce suicide by 10% or by 20%. And that's really, really hard to do and really ambitious, but you're not gonna set for zero if you don't aim for zero, right? If you can't be satisfied if you just reduce suicides by 10%, people are still dying by suicide. It's hard to do, but you have to set ambitious goals to achieve ambitious goals. That's the airline industry, sets for no disasters. The nuclear industry aims for no disasters. Suicide care has to be the same. Next slide. So as I said, people are touching our healthcare systems. They are seeing people within the months leading up to their death. And we have to address suicide in the healthcare system to really reduce suicides in the country. Next slide. So we see the zero suicide is accepted as a core responsibility in healthcare. Patient deaths are not treated as inevitable. It uses best practices and continuous quality improvement. But most importantly, it's embedded in a system-wide culture change so that any door that a patient walks through, any clinician the patient sees is the right door getting good quality care in a system that has their back with a just culture, a culture that is not looking to blame somebody when suicide occurs, but looking to improve, learn from, and develop new policies and trainings to ensure the best care possible going forward for their other patients. Next slide. And it works. This is Henry Ford Health Systems data. They reduce suicides for patients under their care by 75%. And we've seen this replicated in many other healthcare systems. But you have to sustain it and be committed to it. It doesn't happen quickly or overnight. Next slide. And I'm gonna introduce our panelists who are gonna talk in detail about some of these various practices. First up, I'm gonna introduce Dr. Ursula Whiteside. She's a psychologist and suicide treatment researcher. Her work focuses on dialectical behavior therapy, DBT, which was developed by Marcia Lenehan. Ursula is the founder of the nonprofit Now Matters Now.org, a free online public resource with a mission to reduce suffering and suicide through science. It's an incredible website. I know she's gonna talk about it, but I highly recommend it. It features video-based stories of coping and resilience through strategies from DBT. I wanna take a moment before we begin to acknowledge the native lands that we're on. And that will also be relevant for the moments that I have with you today. In my 20 years working in healthcare with suicidal patients, two major themes seem to arise over and over and over again. And those are that as providers, as clinicians, we often feel very stuck to support our suicidal patients. We don't feel like we have the resources and the referral sources to do the best care. But in talking to people who've been suicidal and who have survived and thrived, they say that very small things, very simple things can make an enormous difference in their recovery. And I'm here to talk to you about those today. What I'm talking about is on the Now Matters Now website, which was actually developed at Kaiser Washington. So the tools and practices that you'll see here today were developed as part of research funding that happened at the University, excuse me, at Kaiser Permanente Research Institute. One of the things that's very helpful for providers to know is that the language that they use regarding suicidal patients really matters. And suicidal patients can smell it. They can smell the judgment and it matters. And simple language changes can make a big difference, including changing our language from committed suicide to died by suicide. Another thing that can be very useful for providers is to have a way to talk about suicide, to have a way to explain it to their patients and to explain it to other providers. And what we have here is Marshall Linehan's Biopsychosocial Theory of Emotion Disregulation. And I've just called it the stress model for short. And what you have here are two different individuals. The person in green is the person whose emotional baseline or stress level is lower than the person in tan. And what happens that for some of us, our emotional baseline, our emotional stress level runs hotter than other people. And that is due to our biology, that's due to social determinants, that's due to environmental stressors, such as discrimination. And what happens is when a stressful event occurs, our emotions rise more quickly. They stay there for longer and they take longer to come down. And for people who have this experience, this emotionality, it can be a very beautiful thing, but also it can be a painful thing, especially because people in the green zone really don't understand somebody who is in the tan zone. They don't really understand someone who's at that peak. So we call somebody who's experiencing that really intense emotionality in response to a trigger. We call someone like that, they're experiencing emotional fire, they're on fire emotionally. And we really know what to do when someone's on fire physically, right? When you're on fire physically, we've learned since elementary school to stop, drop and roll. It's in the back of our brain, we've had it there so long, but we've never learned what to do when we're on fire emotionally. And Dr. Mordecai was talking earlier about impulsive suicide attempts. And sometimes what happens is people think, well, they throw up their hands, well, maybe there's nothing we can do in that situation because it was unplanned. We're using the term unplanned more and more. And this is reflected in the research that my colleague Julie Richards and I did at Kaiser Permanente Washington Health Research Institute. We're reflected here in this statement. And this is a person who recently attempted suicide, said, and many of our interviewees said this, I didn't wake up in the morning and think that I was going to kill myself. The good news is that that intense experience of emotionality that overcame this person following a very stressful trigger and led to their suicide attempt. The good news is that there are things you can do and to manage a situation. And one of those strategies is called ice water or cold water. It's a dialectical behavior therapy strategy from this treatment that Julie mentioned in the beginning that is shown to reduce suicide attempts. So I'm gonna show you an example of ice water. So these are simple things that healthcare providers can orient patients to. This is me putting my head in a bucket to demonstrate in a video how you would use the strategy to help reduce intense emotional arousal, to bring that emotions down when the person is emotionally on fire. It is also a bit painful. So that's me demonstrating and trying to bring a little humor here. It hurts a little bit. But what about for the clinician in the room? The person who is sitting with the patient, the primary care provider who's sitting with the patient who came in because they've got diabetic nerve pain. But then in the process of screening for depression, it turns out that this person is having suicidal thoughts and not only are they having suicidal thoughts, but they have a plan to harm themselves in the next few weeks. What do you do? In this situation? Well, in my work with people who've had suicidal experiences and from my own personal experiences having had suicidal thoughts, these are what they say is most helpful. That if you are sitting with somebody who's suicidal, the first and most important thing is that you do not panic. And sometimes it helps to remember that the vast majority of people who have suicidal thoughts, even severe suicidal thoughts, do not go on to kill themselves. So you can slow down and be present with that person. And not only being present, but make sure you're providing hope. And I'll talk about another way to do that in a moment. So what to do? Recommended standard care for suicidal patients includes something called safety planning. These first two steps are safety planning. Having somebody in the session or in that encounter put the suicide prevention lifeline in their phone, reducing the distance between them and help. And addressing guns, it's always important that it can take a lot of time or a little time, but if it takes a lot of time, it's definitely worth it with a suicidal claim. And give someone a caring message you've been hearing about caring contacts. This is an example of a caring contact. So I'm the provider. This is the patient I just described. And we've had a discussion about getting the guns out of the home and having them stored elsewhere for now. We've had him put the suicide prevention lifeline in his phone. And then what I say at the end is, I said, I know we've only met for a few minutes, but could you hold on for a second? I'd like you to give you something to hold on to. I know right now that not a lot of people in your life are happy with you, but I want you to know I'm looking forward to seeing you again. And then just take a few minutes to write this note. That whole discussion took less than a minute, but we know is that caring contacts can prevent suicide. And providing hope can mean things like I'm looking forward to seeing you again. I see that you have gone through hard things before, and so I have a lot of hope for you. Those are the types of things, or I like you. It's communicating that in some way. This is the card that you can get on the Now Matters Now website, or you can write it on an after visit summary for primary care or otherwise. This is a nowmattersnow.org website that I've mentioned before. It has a ton of resources, and it's structured around dialectical behavior therapy skills, which are those tools like the ice water to manage emotional distress and cope ahead. We're gonna watch an example video from that website. So the skill of opposite action is where you, exactly what it says, do opposite of what you feel like doing. I was depressed, and it was, when you're depressed, I found that with me, I wanted to stay in, I wanted to stay isolated, not do a lot of activities. And so with opposite action, you do exactly the opposite of what you feel like doing. I had to go to group and it was cold outside and I was nice in my warm bed. I would think to myself, instead of just trying to see the whole morning, take it in, which would be overwhelming, I would just tell myself, I'm going to just sit up and stretch and see how good that feels. And so I would do that. And then the next step would be, I'm just going to go take a warm shower and see, enjoy that. And then I would go further. I'm going to just get dressed, do my favorite outfit, and get all fixed up, do my hair, do my makeup. And that would help me to start going. When I did, I'd step outside the house. I remember I had to go catch the bus up a hill, a really steep hill. So for that, I would just say to myself, I'm just going to take one step. And then I told myself, I'm just going to take one more step and one more step. And before I knew it, I was up the hill. And of course then I would reward myself with coffee because I love coffee. So I found that that opposite action is one of the skills that to me is really what made the difference between how I was feeling and what I was doing. This resource, a paper's coming out, actually at 10.45 a.m. today that shows that this website is associated with reductions in suicidal thoughts. So visits of only minutes, people reported, reduced suicidal thoughts, reduced negative emotions. And also, this was true for middle-aged men. So we're excited about that. That's the Journal of Medical Internet Research. The idea with this website is that people would have the tools to plug into these different pieces of the stress model. These are all skills or tools that are available on that website. I want to leave you with this, which is that evidence-based treatment for suicidal people is really expensive. And so I think we need to be thinking as this work moves forward with suicide prevention that what we create needs to be readily accessible and that people who are in situations that are unjust can benefit from additional strategies to manage that experience. And that doesn't mean that that's okay, that that situation is happening. Thank you, Ursula. Next up, we have Pavan Samasetti. He, as the leader for suicide prevention at Kaiser Permanente, Dr. Samasetti, works closely with all its regions to raise the national standard for suicide care. He is a passionate advocate for the Zero Suicide Movement and regional physician lead for Kaiser Permanente Suicide Prevention Initiative in Portland, Oregon and Southwest Washington. Rather than relying on heroic efforts of individuals, he promotes combining system-level safety nets with person-centered care to treat higher risk patients within integrated healthcare organizations. Dr. Samasetti is board-certified in psychiatry with the American Board of Psychiatry Neurology and he's the Assistant Chief of Mental Health at Northwest Permanente. Hi, it's an honor to be here. I'm really, really excited to see all of you. And if we end up running into each other afterwards, Pavan rhymes with oven. So, Samasetti is, it's actually pretty easy. It looks hard, but it's actually pretty easy. So I'm a psychiatrist, I'm a Permanente physician. In Northwest Permanente, in serving Oregon and Southern Washington. And there's a lot of non-Kaiser people here, so just to kind of do a little background, Kaiser Permanente is actually made up of our eight different Permanente medical groups and our Kaiser Health Plan and our Kaiser Hospital. So it's not necessarily just one clean, small lean system. It's quite a big organization. There's these three entities or three pillars work together to keep the members' needs front and center. So we all work together to make sure that we're improving the lives of our members that we're saving their lives, essentially. So it's a big honor, it's a big responsibility and it's very difficult to introduce change. So that's what I'm here to talk to you about is how do we implement these principles of zero suicide in a system such as Kaiser Permanente? And I'm also just really happy to see other people from other systems really excited to hear about what the VA does and we kind of look to these organizations as giants in the field and we take inspiration. So it's just really, really cool. I'm kind of a fanboy. So two questions that I'd like you to remember. One, is suicide preventable? I know that kind of sounds weird, but just keep that in mind. The second question is how does Kaiser Permanente influence a culture of safety for its patients and its staff? So that's what I want you to take away from today and I'll go into each one. So it's not a rhetorical question, is suicide preventable? I assume that since we're all here in a forum called Taking Action to Prevent Suicide, that we all believe that suicide is preventable. But not all of our patients believe that and not all of our staff believe that and it's really important that we acknowledge that. The Zero Suicide framework is amazing. We saw those seven pillars, seven steps, seven strategies and how we introduce it. And you can't just go in and say, now everyone's gonna prevent suicide, everyone's gonna do this, everyone's gonna do that. Staff don't respond well to that. We have a ton of physicians, a ton of staff. We work with Zero Suicide from everybody from our front desk, from our MAs, to our primary care physicians, our behavioral health specialists that are integrated in primary care, our addiction medicine counselors, our psychiatrists, our therapists. So Zero Suicide affects everyone and we need to talk about it in a way to inspire everyone to take this challenge on. And one of the things that I found is we need strong leadership. We need to have frank conversations with our staff about the trauma that they experienced in being a person in this difficult world but also treating patients that didn't make it. That's, I think the hardest part about being a clinician is when you've seen someone and they end up dying by suicide, that grief that a clinician experiences really sort of stays with you. People feel powerless. I felt powerless when I lost patients. There's obviously the loss, but how do we get back to work? How do we go back to the clinic and take care of these patients again? We kind of wrap ourselves in a blanket and say it wasn't my fault. There wasn't anything I could have done. This is an occupational hazard of being a mental health professional. That suicide can't be prevented. That's how a lot of us can cope. And so when a leader comes in and says we're gonna just change this and we're just going to say that suicide is preventable, you have to recognize that not everyone will believe it. And I think that strong leadership that's willing to be vulnerable in front of their peers, in front of their colleagues can inspire change, but they also have to acknowledge that people have to take some time to actually believe in a mission. And I usually kind of use a mindfulness framework. I kind of mentioned that this could be difficult, hearing that this is what Henry Ford's done. This is what Centerstone's done. This is what the VA's done. And you might start to get some anger when you hear about these things and just notice it, try not to act on it, keep an open mind. There may be a reason why you feel anger. It may be that you're trying to protect yourself from experiencing the trauma of loss again. So the next piece that I wanted to talk about is what is Kaiser doing? And really, when we influence culture, we're really focusing on observable, measurable change. Basically, it's data. And we have three vital behaviors that we're constantly trying to monitor. And the big work that we've done in the last few years is really making sure that we're capturing the work that we're doing as discrete data. So we know exactly how we're doing it. For a long time, we've been doing the PHP9, which is a screening and monitoring tool for a depression. And so we've known which of our patients have tested positive on that ninth question, the question about suicide. A lot of times, our clinics were doing the Columbia Suicide Severity Rating Scale. But we didn't know when they were doing it, if they were doing it at the right times. So a couple of years ago, we introduced it as a documentation flow sheet within our EMR, within our electronic medical record. So now we know. We know at clinic X, 80% of patients that are testing positive on that ninth question, they're following up with the Columbia Suicide Severity Rating Scale. Maybe at clinic Y, only 50%. And so we have to figure out why that is. We go to clinic Y. We devote more resources on training. Maybe there's staff turnover. Maybe there's a new manager. Maybe there's something wrong at the clinic. Maybe the form that they're inputting changed in some way. So that's how we're constantly monitoring our culture, our safety is through the use of data. And very recently, we've introduced the safety plan, the Stanley and Brown Safety Plan Intervention, also as data. So now we know which of our clinics, when a patient gets Columbia, if they score a certain like three or higher, how many of them are going home without a safety plan? Which departments, which clinics? And we can work on making sure that we're training our folks to have those conversations. So just the Columbia is amazing. Just what's unique about what I think that Kaiser is doing is we have, this is just a paper example, a self-report. We're also introducing it in a tablet format in Southern Cal, Northern Cal, and Georgia, and then soon to be other regions. And so we see that the self-report version of it is actually a little bit more sensitive. People don't feel quite as judged. A clinician might misword the questions and we may not get the answers that we want. So we're trying to make it easier for our staff to get this information before they see the patient so they can address suicidality right away. And I like to think of the Columbia as a defibrillator. When I go and speak with primary care doctors or emergency room doctors, they like these kind of other analogies because any layperson can use a defibrillator. Any layperson can administer Columbia. You don't need to be a mental health professional. And the Columbia is endorsed by all these organizations, some of you are already in this room. This is the Stanley and Brown safety plan. It's the template that we use that we recently made into our electronic medical record. I think this is sort of the secret sauce. When we've introduced this in Kaiser Permanente Northwest, my region, we had an all staff training for all of our mental health and addiction clinicians and we really saw a drastic reduction in our suicide rates. And it was quite impressive and the staff took to this training quite well. And we haven't introduced it yet as electronic so we're really excited about that so we can make sure that the staff that are treating the highest risk patients have a real comfort to the fidelity version of using this tool. I was asked to kind of talk about predictive analytics and I wasn't surprised because that's probably what I get asked about every week or every other day from people in my region, from staff in other region. Last year, the Kaiser Center for Health Research published a study along with Henry Ford where we leveraged I think 20, 25 million member records from all of our Kaisers regions throughout and we found that combinations of certain data points were predictive of suicide risk that if you can combine five data points or so you can have like maybe like an 80% chance of predicting if someone's gonna attempt or die by suicide within the next 90 days. It's really exciting. It almost sounds like minority report, you know, like predicting the future. It's not different I think from predicting someone's risk of having a heart attack, risk of congestive heart failure. You're just taking data points. It's a little bit, I guess kind of like AI. You know, in a clinician when I'm seeing patients, you know, I take what the patients tell me. I look at their history. I administer the Columbia. I have a clinical picture of what this patient's risk is. This will be a really cool tool for me because it's looking at things like an emergency room visit, the presence of an antidepressant prescription, prescription of an opiate or a benzodiazepine, you know, the PHQ9 score. All of those data points that I can't calculate in real time, it's telling me as sort of a safety that I need to stop and re-look at this person's suicide risk. So we're really excited about it. I would say that it doesn't replace the human touch. That really what's helpful is the Dr. Whitesides. You know, we need to make sure that we have a therapeutic alliance that we care for our members. But this is just an additional tool for us. So we're not being replaced by computers. So is suicide preventable? Just remember that. And you know, we use, how Kaiser uses data to influence a culture of safety within our at-risk patients. Thank you. Thank you, Povins. So much information crammed into 10 minutes. I hope you're all taking really copious notes. So Dr. Cornette is lead public health advisor in the suicide prevention branch at the Substance Abuse and Mental Health Services Administration, SAMHSA, and past executive director of the American Association of Suicidology. Dr. Cornette previously supported the research and program evaluation and data and surveillance divisions at the Department of Defense Suicide Prevention Office and was the military suicide subject matter expert at the Center for Deployment Psychology. She spent 10 years in the VA system where she was Visin 12 Suicide Prevention Director responsible for overseeing suicide prevention activities at the seven VA facilities under Visin 12. Dr. Cornette has received federal and private funding for her program of research on suicide risk and she's presented and published extensively on civilian and military suicide prevention. Good morning. Okay, so we have a good bit of information to cover today. I may not hit every slide. I'm going to try to hit the high points. And for those of you who aren't familiar with what SAMHSA does, SAMHSA provides grant funding for a number of suicide prevention endeavors nationally and among the endeavors that SAMHSA funds include grants focused upon zero suicide in adults. SAMHSA also funds the Suicide Prevention Resource Center that Julie was discussing earlier and SAMHSA also funds the National Suicide Prevention Lifeline which I know many of you are familiar with. That's just the standard disclaimer. These are my personal opinions, not that of SAMHSA, HHS or the U.S. government. Okay, so the main focus of my talk today is going to be on acute care transitions. One of the things we've learned a lot about in recent years is that periods of transition are critical. And I think having worked in the clinical space as well for a number of years, I think a lot of us have maybe known this or thought of this anecdotally for periods of time, been concerned about patients, at acute risk who were being discharged from an ER from an inpatient unit, but increasingly now we have data to really support that that's the case. And of course it makes sense, right, that some of our most acute, highest risk patients present to ERs and to inpatient units, okay? These can be challenging transition times, particularly if we're not working within the benefits of a closed system. It can be challenging to facilitate transition, but there is strong evidence now that these sorts of interventions can be lifesaving. There is evidence of the period, a lot of evidence now that the period following inpatient discharge is actually the time of highest risk for death by suicide. So Marcia Valenstein and her colleagues in the VA did a very large-scale study a few years ago in veterans. And while she found that while all transition periods that they looked at were high-risk times, that it was the period 10 weeks following discharge from inpatient that was the highest risk time period. This is actually based upon some data that SAMHSA collects. So some of you may be familiar of the National Survey of Drug Use and Health, sort of one of SAMHSA's hallmark surveys. And so we have data now. This is a review of data from 2006 to 2013. This is a self-report measure. And one of the things we've learned is that in terms of emergency department visits related to suicidal thinking that that rate increased roughly 12% annually and increased a little bit higher in the Midwest at 15%. By 13, we were finding that more than 900,000 ED visits related to suicidal ideation had occurred. And these represented about 1% of all adult ED visits. Close to 75% of those admitted to the same hospital or were transferred to another facility in terms of the disposition of those folks. This is more data from the NISDA. So based on that data, we were able to determine that 3.2% of adults who reported making a suicide attempt died by suicide within 12 months. And that actually among men 45 or older and without a high school education, it was 22%. So this is basically, I'm gonna be presenting a few slides and I apologize somehow in transitioning this to the Kaiser template that the citation fell off of this one slide. But I'm gonna be presenting some data from Mark Olson who's done a number of very rigorous studies looking at what happens to folks following discharge from inpatient and from ER who are at risk or who have presented with self-harm. So what you see here in blue are suicide rates. And this is a large sample. So it's over 32,000 patients and this is youth. So ages 18 to 24. And this happened to be a cohort of those receiving Medicaid and they were followed for a year. And basically what you can see here is that those who are presenting with deliberate self-harm when you look at all these different demographic categories, men and women, different age groups, different races, white, black and Hispanic, you see that those presenting with self-harm have substantially higher suicide rates than those who do not. And the comparison group here are the CDC rates for those respective demographic groups. Data from the same study here. Again, just highlighting the relative rate. Again, these were all folks that were presenting to ERs with self-harm. Self-harm, by the way, I apologize for not defining that. As defined in this body of work, deliberate self-harm is according to the ICD-10 code. So basically the idea is any self-harm, intentional self-harm, whether or not there was suicidal intent. So just to be clear about that. So you can see that these are all elevated in terms of rates per 100,000, but in particular, we see that among those who recently had had inpatient care, and this was inpatient care in the past 60 days, had a very elevated rate of 242 per 100,000. Those who presented with violent methods of self-harm, and those included not only firearms, but hanging, drowning, other violent, jumping from a height, other violent methods, had very elevated rates relative to those who presented with more non-violent methods of deliberate self-harm. The data presented here is actually by Chang and colleagues. It's presented in JAMA psychiatry, and this is a review article. And basically, and it was pretty comprehensive looking at any article that had referenced discharge over a 70-year period. And I'm presenting just a small subset of that data here, not all the age groups that were examined. So in the subset of data from that study, we're looking at 20 studies. There were 120 suicides within this age group. And basically, when you looked at the range, the average suicide rate was 158 per 100,000 person years. And again, if you think about, and this is intentionally data from 2015 to match the timeframe that this other data was collected during, but if you think about the rate of 14 per 100,000 you can see, or five per 100,000 for women, you can see how elevated those numbers are. I need to be efficient here. Just a couple of examples of some international work that's been done, and again, this is just a really small subset of kind of the whole body of literature that exists. This was a large-scale study looking at more than 2,000 suicide deaths and basically found that the highest number occurred in the first week following discharge. And then I wanna talk just for literally a couple of minutes about the importance of care transition intervention. So if we know that care transitions are periods of high risk, what can we do about it? And happily, I know that Dr. Franklin touched on some of this earlier today and here discussion of caring contacts. That is one type of a transition intervention. We'll be talking about that and a couple of others. And actually, mostly I'll be presenting data about why these are important. So this is an example, and I apologize, it's a little bit tricky to follow, but basically if you look left and right, the difference here is folks who presented with deliberate self-harm, whether or not they had a mental health assessment in the ED. And you can see just looking left and right that risk for future self-harm, repetition of self-harm is significantly higher in those who did not have that intervention while they were in the emergency room. And looking at the bottom of the slide, you can also see that there's a difference in terms of whether or not folks presented with mental health issues. So it's even a bigger problem, if you look at kind of the bottom right corner, I guess bottom middle, it's even a bigger problem for those who presented with mental health issues and had no mental health assessment. Also just critically important, and I know this is common sense to everyone in the room, but to be thinking about everyone who presents to an ER is a potential suicide risk, right? People who present with all sorts of distress, including physical distress, may well have other things going on mental health-wise, even if it's not their presenting concern. A study by Fleischman and colleagues, and just really briefly the intervention here that I'm gonna be talking about was a follow-up, and you'll notice that's a theme with a lot of these interventions. That involves psychoeducation with the patient, checking in on how they were doing with their safety plan, and then psychointervention with the patient. That involved discussing suicide behavior as a sign of distress, discussion of risk and protective factors, alternatives to suicidal behaviors, coping strategies, and referral options. So basically, again, this was a large-scale RCT, looking at suicides in eight hospitals across five countries, and they found that those who would receive the intervention and the nine follow-up contacts over the 18 months were significantly better off in terms of lessened risk for suicide death. Not only were they at significantly lower risk for suicide death, but they were also a significantly lower risk for death by any cause. Okay, so again, important to recognize that not only do we need to be looking for suicide and kind of everyone who presents, but we can have impact on other outcomes with some of these interventions potentially. Some of you may be familiar, this motto study is kind of the one that's often cited. It's a really hallmark piece of work in the field that was really the first one that showed that something as simple as a carrying contact could have such a profound effect. And basically, the bottom line is that those who receive the carrying contact relative to those who didn't had significantly fewer deaths by suicide as an outcome. I will just mention very briefly that it's really exciting and important when we have research out there that focuses on suicidal behaviors and deaths in particular. A lot of work focuses on ideation, which is also important, but it's difficult to show a change in suicide deaths as significant change. And so this is really exciting work. Another study by Carter in 2005, similar sort of a design with postcards and follow-up showed an approximately 50% reduction in attempts. Just really briefly, I won't go into the detail here, but, and I didn't catch everything that Dr. Franklin talked about this morning, but SAFE, FED, and ED SAFE are, of course, excellent examples of emergency room interventions that have been implemented in the private sector and in VA. There's also SAFE-MILL, which has been implemented in active duty settings. And basically the idea is a safety plan intervention with follow-up is the design. And we've seen some really exciting and positive results as a result of that work. An example here of a SAMHSA-funded project through our Garrett-Lou Smith program that showed a 40% reduction in suicides with follow-up being a mandated part of that grant. And the Military Continuity Project, again, showing this 45% reduction. Should I skip this slide? Do you want me to skip it? Okay. Okay. Something I'd encourage you to actually just look at in line. Julie referenced the Action Alliance Care Transition or the Action Alliance in general. The Action Alliance now has recommended standards of care for transition periods. It might suggest that you actually, you can just find this online if you go to the Action Alliance website and if you enter recommended standard care, you'll find the recommendations for care transition put together by the Action Alliance. So I think I've hopefully sufficiently demonstrated the importance of care transitions and some of the interventions we can use to address those. And thank you for your time and attention. Thank you, Michelle. So to go into some questions for our panelists, we've heard about a lot of best practices today and Ursula, I'll start with you. How should someone who attended today's event get started on trying to implement or change their healthcare system using these best practices? I think what we see when we're going into train new health systems is that things go much better when you've had those conversations and inspired leadership from the beginning. As many of you know, if they're not on board, then it's much harder to get things happened. But not only leadership, but the frontline champions make such a big difference. And so putting the time in upfront before going to do a training, I think can make things go much better. I'd agree. I am a zero suicide champion and I started off for my region. And I think the key for Northwest Permanente was that we have a program manager that's assigned to suicide prevention, which wasn't the case for all of the region. So it really helped to keep us organized and do all of that pre-work, because there's a lot of work that goes into a training, into getting leadership by in all the seven pieces of the zero suicide model. So really kind of working with leadership, but also having sort of a dedicated staff person, even if it's not their full time, but who's driving the initiative so that they are the hub and everything goes through them. Exactly. So if you knew then what you know now at Kaiser, what would you do differently as you guys have been involved in a wonderful suicide prevention work and the adoption of zero suicide? What might you have done differently if you knew something then? So I've thought a lot about that because we all have regrets, but I think making sure that we keep the principle of making it super easy to do the right thing, always at front and center, trying to get staff to do something different, whether it's a mental health clinician or a primary care doctor. If we don't make it easy for them, we actually put them at risk because they know what the right thing is to do. Like they should be asking these questions or they should be referring these patients, but we make them feel guilty if we didn't make it easier for them to do. So I think that's one thing that I would change is make sure that the electronic medical record is like super clean and easy to use that we make the whole process like foolproof. The other thing is really explaining the name Zero Suicide before you introduce it into a system. We kind of later on found it's better to explain it as if we're seeing zero defects in our care for suicidal patients because our clinicians feel very guilty. When they lose a patient, they feel like the organization was shooting for zero and I struck out and now I'm bringing the whole batting average down for the entire team. So we really don't want our clinicians to feel blamed at all. So how have you in that vein, how have you managed because suicide deaths have occurred despite these impractices being embedded? How has your system kind of bounced back after a suicide has occurred? Well, that's an ongoing process for all of our regions. I can speak to what we've done in our region and what we're trying to do for the other regions is having a really strong care for the caregiver program. I think our Southern California region is probably the strongest with that, where not just from suicide, but from an overdose or an unexpected death, like when we support our clinicians after a trauma that really helps and really it's debriefing it in a way that's not traumatizing and really putting the onus on the system. It's always the system's responsibility if a clinician didn't have time to do a risk assessment, the system should have been able to make that clinician have time. If the clinician didn't know how to do a safety plan intervention, the system needs to make sure that we're training all of our staff. So really trying to take it off of the individual and put it on the larger organization. What, Ursula, maybe are some common obstacles you've seen as healthcare systems have looked to adopt these practices and how have they overcome some of these obstacles? I think starting with policies and procedure changes, that it can be difficult to do this on your own. I think that's what's really helpful about attending like a Zero Suicide Academy or using the zerosuicide.com website, is it has all these examples of how people have done these things already. I think that that's one thing. And I just in case I didn't mention it, I'm not sure I spoke about the website at zerosuicide.com but there's also a really robust listserv that's free and people can sign up for. And I think people, it's one of the most gracious communities I've ever been a part of. I think people don't wanna reinvent the wheel and so people throw their questions up. Do you have policies for youth or how have you trained your crisis line staff and people very willingly share? So another resource might be to sign up for the listserv. I think too, it can be really intimidating to try and train all your staff on evidence-based interventions for suicide prevention. So I think that giving systems permission to say part of training, which is an element of zero suicide, part of training is training staff up to PAR on all of these new things that you're implementing and that you get credit for doing the train element of zero suicide for doing that work, making the system responsible for that change. And I think, Pavin, you mentioned that that despite rolling out maybe a safety plan tool or Columbia people might have said if they weren't trained in using it at first, they were just sort of being told what to do but not how to do it. Right, and that it's effective, that it does work so people really have to believe that it's gonna work. Do you have any other additional ideas about sort of commonly faced obstacles that you've experienced and how you all overcame them? So with a large group of physicians and a large group of staff, sometimes we'll get pushback and say like we don't need to change what we're doing, you need to hire a thousand more therapists and then we can get our suicides closer to zero. And it would be nice if there were that many clinicians out there were always hiring but really trying to make sure that each clinical touch has safe practices to be able to screen, assess and treat our suicidal patients. So one of the things that we did to kind of judo move that is we asked our staff, our labor to participate with us in developing our policy and procedure. So we said, this is what we want our standard of care to be but we want you to help us figure out what that looks like. So we went to our emergency room, mental health clinicians, we went to our rapid access clinicians, we went to our telephone triage folks and we gave them these large pieces of paper and had them map out the workflow and they gave us ideas of how they could clean it up. And so that kind of working together was really successful I think for at least in the Northwest region. Michelle, you talked a lot about the research and certainly the use of some of these specific intervention in military and veterans. What does the research say if you know about doing some of these practices with youth or with tribes or with other populations? Yeah, it's been less extensively explored, especially with tribes. There has been some work in young adult and youth populations but the majority of work has been looking at adults. So where might you invest your healthcare dollar? I mean, maybe you can't say this because you're SAMHSA, so I can't. That's the one thing I can't say. So perhaps if either of you have any thoughts about where research could go that would really help to improve healthcare. Well, I'm really excited about creating storytellers. So every time somebody has gone through a mental health or addiction issue, there's a potential for a beautiful story and then there's a potential for a lot of people that have exposure to that story and maybe find it useful. So I think that I'd like to create an army of storytellers and then evaluate whether that's effective and I think the tool that I shared today is one potential place that something like that could be done. But I think there are new innovative things that we can do but we just can't take forever to do them. And I think that's one of our limitations. I like storytelling and I think that's why I got into this field and what keeps me going. So that's totally, I'm curious about how that would go. If I had a Christmas list, what would be on my list? I think probably really investment in our infrastructure and the electronic medical records and just to really make it super easy for our staff to be able to ask questions about suicide to do the safety plan. So I talked about the vital behaviors and we're already starting to introduce tablets into our clinics in Georgia and Northern California and Southern California and I can't wait for my region to get it because I would love to be able to know when someone is suicidal before I even go out to the waiting room and get them. And I mean just in general, I'd love that to be there for primary care as well. And I just want to make it, just reiterate that like 10 times, we want to make it really easy to do the right thing. Just like somebody in the OR, we're not going to let leave a forceps in someone's body. We're going to do a count. We're going to make, there's a process for that. We can totally prevent that from ever happening. And so instead of thinking of suicide as a never event, want to make sure it's whenever somebody presents with these symptoms, these are always going to happen. We're always going to assess where it's going. We're just going to make it as super easy as possible. So are there any questions from the audience? And I think there's a microphone being passed around. Can you hear me? Okay, great. So hi, thank you so much for the panel. One of the things that I'm curious about within the care systems is how are we empowering and utilizing family members as mandated reporters, for instance, or first lines of protection and defense for other family members who are returning with trauma symptoms that then could be predictive indicators for suicide. So how are your health systems working with parents of maybe wounded soldiers or wives of veterans coming back that deal with a lot of the vicarious trauma issues from those incidents and having them be filters into your system to create a larger spectrum of care? Michelle, do you want to answer? I can, yeah, I can start with that one. So I didn't put that as a vital behavior yet because it's not, we don't have it as observable, but we really want to make sure that when we've identified someone that's at risk for suicide, that we have a conversation about who's important to them, whether it's a loved one or a family and have them sign a release of information before they leave the office. So I would love to have that as something that we can record as data that is an always happen event after someone presents with high risk of suicide. The other piece is the Stanley and Brown safety plan intervention has a piece about talking to family. And I think something that we've learned is that you can have the safety plan with the patient and we talk about who are you gonna rely on when your symptoms get to this level, but we also have to make sure that they talk to that person and that we invite that person to come in for the next session. So that's a little bit of a pitfall we found that we introduced the safety plan intervention and then we found some of our parents of members were saying, hey, I'm on that list, but nobody told me I'm on that list. So when we release someone from the emergency room or from, we see someone in the clinic, we have to make sure that we call them. And I think Centerstone is another agency that I really look at as an inspiration and they have an always event model where they make sure that they confirm that lethal means are removed before the end of the day. So if they see someone at one o'clock in the clinic and they're suicidal, they don't just tell the patient, hey, we need to secure access to your firearms. They also reach out and confirm that before the end of the day. And I can also just add piggybacking on Pavan's comment that I think the safety plan is again, is a really useful tool as he was saying. And what I have typically done in my practice is that with someone at risk for suicide, I use that as an opportunity when they're providing the contacts for people they would feel comfortable reaching out to. I use that as an opportunity often to get consent from them to contact that family member or friend in a time of distress. And so for me, that's been helpful because I think a lot of clinicians struggle when there is an acute crisis and they're thinking about potentially violating confidentiality, it can eliminate that problem if you've gotten informed and sent ahead of time. Yeah, I think, I mean, I think it's one of the keys is education when you're doing suicide care, you really have to educate the people providing the treatment, educate the system, educate the patient and educate their family and loved ones and not shy away because of HIPAA, not make assumptions that your providers know and not be afraid to really sit down and collaboratively look with your patient about what is this thing that we're treating you for? We educate people in the medical world if you have a new diagnosis, a heart disease, we challenge, we do a lot of education about that. We have to do the same thing in mental health and specifically with suicide care. So I wanna thank all of our panelists for today's conversation and thank you for allowing us to be here. My job is to tell you that you have a 10 minute break now too. So thank you very much.