Behavioral Health Integration Collaborative

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Behavioral HealthIntegrationCollaborative“Practical Strategies for Managing Suicidal Ideation and Reducing Risk”September 23, 2021 2020 American Medical Association. All rights reserved.

DISCLAIMER AND NOTICESThis Webinar is being made available to the general public and is for informational purposes only. The viewsexpressed in this Webinar should not necessarily be construed to be the views or policy of the AMA.The information in this Webinar is believed to be accurate. However, the AMA does not make any warrantyregarding the accuracy or completeness of any information provided in this Webinar. The information is providedas-is and the AMA expressly disclaims any liability resulting from use of this information. The information in thisWebinar is not, and should not be relied on as, medical, legal, or other professional advice, and viewers areencouraged to consult a professional advisor for any such advice.No part of this Webinar may be reproduced or distributed in any form or by any means without the prior writtenpermission of the AMA.All rights reserved. AMA is a registered trademark of the American Medical Association.2 2020 American Medical Association. All rights reserved.

About the BHI CollaborativeThe BHI Collaborative was established by several of the nation’s leading physicianorganizations** to catalyze effective and sustainable integration of behavioral andmental health care into physician practices.With an initial focus on primary care, the Collaborative is committed to ensuring aprofessionally satisfying, sustainable physician practice experience and will act as atrusted partner to help them overcome the obstacles that stand in the way ofmeeting their patients’ mental and behavioral health needs.**American Academy of Child & Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics,American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association,American Osteopathic Association, and the American Psychiatric Association. 2020 American Medical Association. All rights reserved.

TODAY’S SPEAKERSChristine Yu Moutier, MDCori Green, MD MS, FAAPChief Medical OfficerDirector of Behavioral HealthEducation and IntegrationAmerican Foundation for SuicidePrevention 2020 American Medical Association. All rights reserved.Weill Cornell Medicine

Strategies forPreventing SuicideChristine Moutier, MDAFSP Chief Medical Officer@cmoutierMD

Public Health Approach to Suicide PreventionNational Collaborating Centre for Mental Health (UK). Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance:Updated edition. Leicester (UK): British Psychological Society; 2014 (NICE Clinical Guidelines, No. pp9.f1

US Suicide Rate (1980–2019)Per .5(1990)12.1(2010)13.9(2019)10.4(2000)Year 1980 - 2019Centers for Disease Control and Prevention. Data and Statistics Fatal Injury Reports through 2020. Age-adjusted rates.

CULTURE TRENDSLanguage MattersAvoid Commit suicide Successful/failedattemptSay Died by suicide Attempted suicide

HEALTHCARE SYSTEMSHealth System Opportunities Suicide hasn’t always been a clinical focus Stigma has limited self-care and patient care 90% suicide decedents seen in prior year 50% within prior month/30% past week 40% saw PC within month of suicide 20% saw MHP within month of suicideLuoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providersbefore suicide: review of the evidence. Am J Psychiatry 2002

DRIVERS OF SUICIDE RISKInteracting Risk and Protective FactorsBiologicalFactorsPsychologicalFactorsSocial andEnvironmentalFactorsCurrent Life EventsLethal MeansSUICIDEAFSP 2014

WHY DOES SUICIDE OCCURTop Scientific Findings Multi-factorial risk, mental health key Access to lethal means matters Genetics play a role but don’t Effective MH treatment matters Contagion is real Epigenetics but often conflated with asking Suicidal mindset Storytelling can also improve outcome Cognitive constriction Connection, processing are protectivedetermine destiny Timing of acute risk Cultural factors (self-sufficiency) Shame/humiliation/despairScience dispels myths

Science is providinginterventions that reducesuicide risk.

HEALTHCARE SYSTEMSSteps Health Systems Can Take Provide education to staff; Lethal Means CounselingRoutine consent to involve fam at the start of TxRoutine screening/assessmentPut ‘Caring Contacts’ in place systematicallyEHR for suicide preventive steps- Referral to BH, communication w family- Safety Plan completed, provided Lifeline- Counseled on lethal means removal

Practical Take-AwaysJust because someone is thinking about suicide does notmean they are at risk of death. Ask and listen.To prevent suicide, we need to address the individual’s driversof risk (go beyond the presence of suicidal ideation or pastattempts).Health systems, clinicians, loved ones have a role to play.Limiting access to lethal means saves lives.There are interventions that are effective in reducingsuicidal behavior.

THANK YOU!Save lives and bring hopeto those affected by suicide@cmoutierMD@afspNational

Clinical ResourcesRecommended Clinical Standards of Care for Suicide ult/files/action alliance recommended standard care final.pdfASQ NIMH Suicide Risk Screening Pathway (NIMH site)C-SSRS (Columbia Lighthouse Project)SafeSide Suicide Prevention Training (AFSP will sponsor PC)Collaborative Assessment and Management of Suicidality –CAMS (Jobes, Comtois) https://cams-care.com/Safety Planning Intervention – SPI (Stanley, Brown) http://suicidesafetyplan.com/Counseling on Access Lethal Means “CALM” (SPRC)

National Crisis ResourcesNational Suicide Prevention Lifeline, 800-273-8255Crisis Text Line Text TALK to 741741Clinician SupportPhysician Support Line 888-409-0141 physiciansupportline.comEmotional PPE Project www.emotionalppe.org/AFSP Resourceshttps://afsp.org/physicianCOVID resources www.AFSP.org/covid19Find Local AFSP Chapter: www.afsp.org/find-a-local-chapter

Practical Strategies forManaging Suicidal Ideation andReducing Risk: The Role of aPediatricianCori Green, MD, MSAssociate Professor of Clinical PediatricsDirector, Behavioral Health Education and Integration inPediatrics

Integrating Mental Health into Pediatric Care:Continuum of Care Prevention/Promotion Anticipatory guidance to support healthy emotionaldevelopment Screen for risk factors to healthy emotional development Screening and Early identification Diagnostic Assessment Making a diagnosis Treatment Refer/Co-manageFoy, Green, Earls: Mental Health Competencies forPediatric Practice, Pediatrics, 2019

Identify and manage suicide risk

Pediatricians Experiences and AttitudesSummary of national survey distributed to post-trainee respondentsthat provide primary care to patients over age 9: 8 in 10 had a patient attempt suicide in their career Only over half feel prepared on suicide preventionSummary of resident survey at one program 100% agree it is the pediatricians' responsibility to identify suicide risk 96% agree it is the pediatrician's responsibility to perform a safety planwhen risk identified22

Role of the PediatricianPhoto Credit: Youth In Health: Inclusive Stock Photography Collection. Adolescent Health Initiative. HeatherNash Photography. 2021Photo credit: American Academy of Pediatrics Suicide Prevention Campaign Toolkit. Used withpermission.

Identification and ScreeningHEADS4: Home, Education, Activities, Drugs, Sexual Activity, Safety,Suicide, Social MediaScreening Tools: PHQ9 Modified for Adolescents (PHQ-A) Ask Suicide Questions (ASQ) Columbia Suicide Severity Rating Scale (CSSRS)24

Identifying Suicide Risk:Screening Tools25

Identifying Suicide Risk:Screening Tools

Identifying Suicide Risk:Screening toolkitmaterials/youth-outpatient/suicide risk screening pathway outpatient youth.pdf

Managing a positive screen:Engaging patient and parent or guardian using commonfactorsH Hope: for improvement, identify strengths E Empathy: listen attentively L2 Language: use family’s language, check understanding Loyalty: express support and commitment P3 Permission: ask permission to explore sensitive subjects,offer advice Partnership: identify and overcome barriers Plan: establish plan or at least a first step

Managing a Positive Screen:Assess Level of Risk and Intervene AccordinglyLow: counsel, refer, follow upMedium: counsel, refer,safety plan, follow upSevere: ensure caregiverclosely monitors patient,remove lethal means fromhome, safety plan, paigns-and-toolkits/suicide-prevention/

Identifying Suicide Risk:Screening ToolsIf yes on any of 1-4 and yesto Q5: Are you havingthoughts of killing yourselfright now?IMMINENT RISKAcute suicidal thoughts needs urgent fullmental health /asq-toolkitmaterials/youth-outpatient/suicide risk screening pathway outpatient youth.pdf

Identifying Suicide Risk:Screening ToolsIf yes on any of 1-4 and NOto Q5, look at Q4 askingabout attemptYesLow risk if 1 year ago, parent aware, received orin MH services, behavior not an imh/asq-toolkitmaterials/youth-outpatient/suicide risk screening pathway outpatient youth.pdf

Identifying Suicide Risk:Screening ToolsIf yes on any of 1-4 and NOto Q4 and Q5?Brief Suicide Safety /asq-toolkitmaterials/youth-outpatient/suicide risk screening pathway outpatient youth.pdf

Not just little adults: risk and protective factors toconsiderBullyingChild abuse, trauma,neglectImpulsive/aggressiveInternet useUnsupportiveenvironment forLGBTQ YouthChronic medicalconditionsEngaged in school or activitiesFuture OrientedStrong socialsupports/connectednessResponsibility to family orpets

Brief Suicide Safety Assessment1. Praise the patient2. Assess the patientFrequencyPlanPast BehaviorSymptomsSocial Supports andStressors“Do you have a plan to kill yourself?” Ifyes, ask: “What is your plan?” If noplan, ask: “If you were going to killyourself, how would you do lkit-materials/youth-outpatient/bssa outpatient youth asq nimh toolkit.pdf

Brief Suicide Safety Assessment3. Interview patient and guardiantogether4. Make a safety plan with the patient andguardian5. Determine disposition6. Provide resources to all q-toolkit-materials/youth-outpatient/bssa outpatient youth asq nimh toolkit.pdf

Counseling about Lethal Means re Final.pdf

Ongoing Care and Follow Up :Complete Stanley & Brown Safety Plan Seeking a defined commitment to safety Not meant to be a safety contract Set of co-directed coping strategies to decreasethe risk of suicidal behavior during a crisis Recognizes personal warning signs Identifies a patient’s support network Involve the patient’s parent/guardianAlways document your safety plan in the EMR

Stanley & Brown Safety Plan TemplateSTEP 1: Warning signs (e.g. thoughts, images, mood, situation, behavior) that a crisismay be developingSTEP 2: Internal coping strategies; Things I can do to take my mind off my problemswithout contacting another person (e.g. relaxation technique, physical activity)STEP 3: People (including phone numbers) and social settings that providedistractionsSTEP 4: People (including phone numbers) whom I can ask for helpSTEP 5: Professionals or agencies I can contact during a crisis Clinician name and number Local urgent care services Suicide Prevention Lifeline Phone: 1-800-273-TALK (85255) Crisis Text Line: Text HOME to 741741STEP 6: Making the environment safeThe one thing that is most important to me and worth living for t/uploads/2016/08/Brown StanleySafetyPlanTemplate.pdf

Ongoing Care and Follow Up39

BHI Collaborative “On Demand” Webinars The Value of Collaboration and Shared Culture in BHIBehavioral Health Billing & Coding 101: How to Get PaidImplementation Strategies for Virtual BHIFinancial Planning: Quantifying the Impact of BHIPhysicians Leading the Charge: Dismantling Stigma around Behavioral Health Conditions& TreatmentPrivacy & Security: Know the Rules for Communication of Behavioral Health InformationEffective BHI Strategies for Independent PracticesAdvancing Health Equity through BHIBolstering Chronic Care Management with BHIHow to Address the Growing Behavioral Health Concerns Among Children, Adolescents,and FamiliesWatch all these webinars and more on the Overcoming Obstacles YouTube playlist now! 2020 American Medical Association. All rights reserved.40

Collaborative Resource – BHI CompendiumThe BHI Compendium serves as a tool to learn about behavioral healthintegration and how to make it effective for your practice and patients.Download Nowto learn how to make thebest decisions for themental health of yourpatients. 2020 American Medical Association. All rights reserved.41

Thank you for joining! 2020 American Medical Association. All rights reserved.

Additional Resources43 2020 American Medical Association. All rights reserved.

Apps and Internet ResourcesSafety Planning Apps (Stanley-Brown, notOK app)ETUDES Brite Path app for clinicians, safety planningNowmattersnow.org (DBT, mindfulness techniques for public)Virtual Hope Box appAFSP.ORG for patient/family/advocacy resources

AMA’s Preventing Physician Suicide Resource The Preventing Physician Suicide online resource providesinformation about physician suicide, how to identify andaddress warning signs and risk factors, and AMA efforts andresources to prioritize mental health and well-being. cianhealth/preventing-physician-suicide46 2020 American Medical Association. All rights reserved.

mental health care into physician practices. With an initial focus on primary care, the Collaborative is committed to ensuring a professionally satisfying, sustainable physician practice experience and will act as a trusted partner to help them overcome the obstacles that stand in the way of

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