Statement of Public Health Issue:
Deaths due suicide, drug overdose, or alcohol abuse, commonly categorized as deaths due to despair, are rising within the U.S., and are therefore identified as an area of public health concern. Primary drivers of suicide align to known challenges associated with low access across the social determinants of health spectrum, including mental and behavioral health, access to housing, and income and job stability.
Suicide prevention, like many other aspects of the healthcare system, benefits from a system-level approach for both understanding of the problem and developing solutions for prevention of the issue. Public health is well situated to maximize a systems-level approach to suicide prevention through leveraging expertise in informatics, data sharing, and epidemiology. In addition to the systems-level perspective that public health can bring to the issue of suicide, many local health departments offer some level of clinical services, including immunizations, family planning, WIC, or maternal/child health management.
Not only can public health clinical services benefit from implementation of a suicide prevention framework, but there is also an opportunity for collaboration across multiple programs within a health department from quality improvement to data and informatics to make progress on a challenging behavioral health issue.
The Zero Suicide framework, developed specifically for use in behavioral health and healthcare systems, is a suicide prevention framework with seven evidence-based components: Lead, Train, Identify, Engage, Treat, Transition, and Improve. The Zero Suicide Quality Improvement project being proposed here is primarily within the Improve area.
Effected Population & Structural Problems:
In Douglas County, suicide is the 9th leading cause of death, accounting for approximately 2.0% of the county's deaths (2020), but accounts for 80% of all violent deaths and 78% of deaths due to firearms (2013-2017). The overall mortality rate due to suicide in Douglas County is lower than the state of Kansas, but the rate has increased over time. In 2011-2013, the suicide rate in Douglas was at a low of 13.2/100,000, but it is currently at a rate of 15.2/100,000.
When examining deaths due to suicide utilizing a different measure of mortality—Years of Potential Life Lost—one can see that suicide can have devasting affects on mortality. YPLL is a mortality measure used to draw conclusions regarding how early in life populations will die from a cause, thereby losing out on potential years of life. In Douglas County when YPLL is used as a measure, suicide jumps to the 4th leading cause of death (2013-2017).
According to a 2019 LDCPH Suicide Prevention Data Brief, males are 3.5 times more likely to die by suicide and over half the people who die by suicide are under 45 years old. Males are more at-risk for death by suicide compared to females as the male-female demographic is fairly evenly split (males represent 49.7% of the population). However, the risk for those under 45 years may be proportionate to the population in the county. Due to the presence of three universities, the Douglas County population skews young. The 20 to 50 year old population represents almost 60,000 people, which is nearly half of the population of the county.
The LDCPH Zero Suicide QI project focuses on utilizing data to improve processes around suicide prevention within the behavioral and healthcare systems. It does this through utilization of a QI lens to understand process improvement and by looking at case studies of patients who have presented at the Emergency Department with suicidal ideation. In both instances, the data represent real people within our community that have been affected by suicide, either through death or ideation.
Primary drivers of suicide are generally related to acute or chronic stress, which could be due to job insecurity, loss of income, or housing instability. The agencies involved in the study are key components of the community's behavioral and healthcare safety, including the health department, the FQHC, the community mental health center, two treatment facilities, and the community hospital. These agencies are the primary agencies providing care and treatment for a population at risk for suicide.
Similarly, untreated behavioral health issues can come with risks of suicide. Therefore, it is vitally important than any project focused on suicide prevention should include behavioral health as a key partner—which this project does. Understanding linkages to care through data sharing will only enhance suicide prevention efforts across a whole system.
Address Health Inequities:
As previously mentioned, the social determinants of health are considered integral to understanding suicide risk. The population analyzed through this project are patients of agencies that work with high-risk and vulnerable patients. For example, the FQHC in Douglas County sees patients without insurance and on a sliding scale and patients of the health department are often seeking Title X services, Vaccines For Children, or Tuberculosis testing and treatment. As a result, the patients seen are often overrepresented from a lower sociodemographic and are un- or under-insured. The agencies in this study are uniquely qualified to see, diagnose, and treat patients who are most risk due to the chronic stress of not having access things like stable housing, health insurance, or a living wage.
The Zero Suicide case studies developed by LDCPH utilizing screened patients who also presented at the Emergency Department with suicidal ideation illustrate the social determinants of health challenges faced. The data source for this is a county-wide resource management system which is utilized by the criminal justice system and community-based providers and requires informed consent. Two examples are highlighted below:
· Example 1: Seen for a Sexually Transmitted Infection; Currently homeless and drug user; Current positive depression screen; History of relative dying by suicide.
· Example 2: Seen for Tuberculosis screening following release from local jail; No depression screen completed.
The belief from the case study development is that data from real-world situations can help an agency think through a suicide and behavioral health care pathway for the patients seen within an organization. Specifically, if public health screens for suicide while also recognizing patterns of accessing the Emergency Department for mental health emergencies, this could be an opportunity for targeted, active education with our patients.
Among the individuals who are working on the Zero Suicide QI project at the whole system level include individuals with direct experience with the behavioral health system, a mental health challenge, and lived experience with family members who have died by suicide. Internal to LDCPH, members of the Zero Suicide Implementation Team include individuals who have lived experience with family members that have died by suicide. Including those with lived experience in the planning and implementation of the project assures that their experiences and voices are heard and that the project is designed in a way to respectful of both the individual and their family members.
Finally, the data source for the development of the case studies requires informed consent by the individuals prior to data sharing and a limited data set is gathered for each individual.
Innovation:
The Zero Suicide framework is a relatively new suicide prevention framework, developing from a task force in 2010-2013. It is primarily developed for healthcare and behavioral health systems and thus far is primarily utilized within those systems, when a prevention framework is utilized at all. Many healthcare systems have yet to fully embrace and implement a suicide framework.
Public health can serve a unique role for Zero Suicide within a community. Primarily, many local health departments see high-risk or vulnerable patients through a variety of services, such as Tuberculosis management or STI testing/treatment. As such health departments can integrate suicide prevention best practices into their clinical management practices.
Secondarily, public health departments can and should leverage their subject matter expertise in fields like epidemiology, data sharing, and quality improvement to move into a Chief Health Strategist role for the system of care to understand and address suicide as a public health issue. This project, with a goal of using data to drive continuous quality improvement to understand suicide prevention within a system, is a prime example of how governmental public health can be drivers of system-level change to address public health challenges. LDCPH has leveraged data-sharing and analytical expertise to work with multiple agencies across a system to assure improvement is made in the area of suicide prevention.
Finally, this project is an example of how programs within a local health department can work together to make progress on a public health challenge. In this project, for the internal data review and quality improvement components, many individuals from a variety of program areas came together to address the issue, including from clinical services, quality improvement, and informatics. The project is a good example of how the Assessment and Assurance portions of the 10 Essential Public Health Services wheel can come together to make progress addressing community health challenges.
Despite the advantages of utilization of a Zero Suicide framework within public health, it is exceedingly rare for local public health to integrate and work from a Zero Suicide framework (according to the Zero Suicide Community of Practice of which LDCPH is a member).
Evidence-Based Practice:
The Zero Suicide framework is considered an evidence-based practice. The framework for implementing Zero Suicide within a healthcare organization is constructed around seven elements, which are considered evidence-based practices for the prevention of suicide. The framework is endorsed by the National Action Alliance for Suicide Prevention for suicide prevention in healthcare systems.
Zero Suicide is considered a new suicide prevention framework and it is not yet widely implemented across the behavioral health and healthcare systems. There is emerging evidence that organizations that implement the framework have success in reducing suicides.
An article published in the journal Psychiatric Services found that mental health clinics that implemented a Zero Suicide framework, and were faithful to the tenets of the framework, had a significantly reduced likelihood of having a suicide incident. The higher the fidelity to the Zero Suicide framework, the more likely the reduction in suicide events.
Layman, et all. (2021). The Relationship between Suicidal Behaviors and Zero Suicide Organizational Best Practices in outpatient Mental Health Clinics. Psychiatric Services. 72. 10. Pgs 1118-1125. https://doi.org/10.1176/appi.ps.202000525.
Finally, Zero Suicide is recognized by the CDC as an identified strategy and resource for implementing suicide prevention within a healthcare system.
CDC. (2022). Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.