Zero Suicide: Quality Improvement Practices among Behavioral Health Partners

Local Health Department: 

The Lawrence-Douglas County Public Health Department is an accredited, medium-sized health department located in Lawrence, KS and serves a population of approximately 122,000 Douglas County residents. The county skews younger in age, due to the presence of three universities. The majority of the population is White, non-Hispanic (approximately 80%), but the largest growing demographic is the Hispanic/Latino population. The population is evenly distributed between males and females. 

LDCPH operates under a city-county governance structure with approximately 45 employees. Services include clinical, case management, community health, informatics, and environmental health.

Public Health Issue:

Suicide is a leading cause of death for Douglas County (9th in 2020) and the rate has risen to 15.2/100,000 from a low of 13.2/100,000 in 2011-2013. In Douglas County, males are 3.5 times more likely to die by suicide and half the people who die are under 45 years old, which is a concern given the county's young demographics.

Zero Suicide is a national framework for healthcare and behavioral health organizations that believes deaths due to suicide for individuals seen within the healthcare system are preventable. It is a framework for healthcare organizations to prevent suicide among their patients. It is not yet widely utilized in public health settings. LDCPH is in the process of implementing Zero Suicide into our operations. This model practice is focused on one portion of the process.

Goals, Objectives, & Status:

The goal of the Douglas County Zero Suicide Quality Improvement project is to weave data into the behavioral health system of care to guide prevention strategies to provide motivation and engagement in suicide prevention work utilizing a QI lens.

The objectives of the project were to:  (1) Access list of Douglas County deaths due to suicide from the coroner (met); (2) Share the list with agencies within the local behavioral health system through the Behavioral Health Leadership Coalition (met); (3) Ask organizations to share "Yes/No" to whether they have seen someone on the list within a year (met); (4) Agencies perform a QI exercise regarding practices surrounding the service to determine if suicide was preventable (completed at the health department, in progress with other agencies); (5) Share general lessons learned with other agencies without compromising personal health information (partially met); and (6) Work with the county's data sharing system to perform QI on high risk suicide patients to construct case studies (met).

Activities/Milestones Achieved & Intended Impacts:

Activities and milestones completed include: Sign-on from behavioral health partners to complete the project, access to suicide death information from coroner, sharing of list with partners, crosswalk of patient service with deaths by suicide, LDCPH internal QI project, sharing of lessons learned with partners, presentation of results at statewide prevention conference, and development of 5 cases studies for  suicide prevention learning.

Intended impact is to have data-driven QI to promote the Zero Suicide framework within our community and to prevent unnecessary deaths due to suicide. The hope is to undersand how suicide care efforts connect with each other across a system. Intended impact within agencies is to increase capacity for case review and develop opportunities to use QI to fully evaluate suicide prevention efforts internally.

Actual impact has been to integrate a suicide prevention framework into the operations and of a public health clinic. It has strengthened partnerships and collaboration between agencies in a behavioral health system. It demonstrates how data can be used to make progress on public health challenges within a system of care and is a successful case study in data sharing at the local level.

Factors Influencing Success:

A factor influencing the success of the project is the Informatics Team within the health department, with senior analysts to assure continual progress. Similarly, the addition of a QI Coordinator to our staffing model greatly enhanced the focus and implementation of the project. 

Another factor influencing success is the Behavioral Health Leadership Coalition (BHLC)--a group of behavioral health agencies that assure the promotion and progress of behavioral health work. The sub-group of the BHLC--the Data Sharing Collaborative--meets regularly to explore innovative methods for using data for progress on behavioral health challenges.

Collaboration and partnership from this collaborative was integral to success of the project. This includes working closely with the coroner to obtain data, with identified partner agencies to assure project buy-in, and with the state-level suicide prevention agency (KSPHQ) to provide subject matter expertise. Finally, collaboration with Douglas County to utilize a resource management system allowed for the creation of case studies around suicide prevention for patients that presented to the Emergency Department with suicidal ideation.

Community Engagement:

Community engagement primarily occurred through partnership and organization collaboration. Members of the BHLC, as well as the Zero Suicide team within the health department, have lived experience with the negative impacts of suicide on family and friends.

Public Health Impact:

The impact on public health practice is to demonstrate an innovative way that data and informatics can be utilized to inform a QI project with the intended impact of creating a standard of care for suicide prevention within a behavioral health system. Additionally, it demonstrates how the different spokes of the Essential Public Health Service wheel can work together to make progress on a issue of community health, including EPHS #1, EPHS #7, and EPHS #9.

Many communities are looking for innovative data-sharing practices to address suicide without breaking HIPAA or other PHI requirements and this project is scalable and replicable for many other communities.

Health Inequities:

The case studies developed around high-risk patients seen in the Emergency Department for suicidal ideation is a demonstration of why suicide needs to be viewed through an equity lens.  The case studies demonstrate that a patient may experience issues along the spectrum of the social determinants of health, such as homelessness, mental health, and substance abuse, while seeking treatment for STI or TB treatment. It highlights the importance of proper screening and the follow-up assurance needed to connect a patient through referrals, even within a public health clinical setting. 

Website:  www.ldchealth.org

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 9^th 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 4^th 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.

Goals & Objectives:

Many of the healthcare and behavioral health agencies within Douglas County, including Lawrence-Douglas County Public Health, have been engaging in, learning about, and trying to operationalize and deploy a Zero Suicide framework with the goal of preventing suicide among patients seen within the system of care. Reducing the overall suicide mortality rate is a stated goal within the Douglas County Community Health Plan (CHP) for the Behavioral Health plank. One of the objectives of the goal is to implement Zero Suicide in order to reduce deaths by suicide from patients seen within the healthcare system.

Within the overall implementation of Zero Suicide, the collaboration and implementation teams have been working specifically on a Zero Suicide Quality Improvement project. The goal of the project is to weave data into the behavioral health system of care to guide prevention strategies to provide motivation and engagement in suicide prevention work utilizing a quality improvement lens. It is considered a best practice by Zero Suicide to do a review of all deaths by suicide for patients seen within the previous 12 months to look for opportunities for quality improvement to prevent future suicide deaths.

The identified objectives of the project were as follows:  

·       Access list of Douglas County deaths due to suicide from the coroner;

·       Share the list with agencies within the local behavioral health system through the Behavioral Health Leadership Coalition, specifically the Data Sharing Collaborative (DSC) sub-group;

·       Ask organizations to share "Yes/No" to whether they have seen someone on the list within a year;

·       Agencies perform a QI exercise regarding practices surrounding the service to determine if suicide was preventable;

·       Share general lessons learned with other agencies without compromising personal health information;

·       Work with the county's data sharing system to perform QI on high risk suicide patients to construct case studies.

Steps Taken to Achieve Goals & Objectives:

An LDCPH analyst served as the project lead; she worked closely with identified stakeholders to make progress on the goal and objectives of the practice.

Successful achievement of the objectives of the project can mostly be attributed to sound practices of data sharing, dedicated collaboration among partners, and shared value around a common purpose (to reduce the mortality rate due to suicide).

Specific steps taken include:

·       Created outline and design of the project.

·       Built relationship with coroner to build understanding of the project and obtain data.

·       Worked with agencies of the Data Sharing Collaborative to create buy-in for completion of the project.

·       Obtained and shared coroner suicide data with DSC agencies.

·       Completed primary overview of the list and crosswalk with LDCPH patient services through the EMR.

·       Completed Quality Improvement around the services provided.

·       Worked with the DSC to share lessons learned regarding the project.

·       Worked with Douglas County to crosswalk patients seen at the Emergency Department for suicidal ideation with LDCPH patients.

·       Created a series of case studies for shared learning.

Prior to achievement of the above steps and the Zero Suicide QI project, the guiding work of the Community Health Plan was utilized to create consensus and energy around issues of behavioral health, specifically suicide prevention.

Timeframe:

While this project did not have a hard deadline as it was primarily exploratory in nature and not part of a budgeted grant or award process, it nevertheless occurred within an identified timeframe of approximately a year. At the beginning of 2022, the Senior Analyst at LDCPH began working with the Coroner to obtain suicide data to share with local behavioral and healthcare system partners. The QI portion of the project took place over the spring and early summer. By fall 2022, the first round of the  project was near complete and results were being shared as part of local prevention conferences. A follow-up portion of the project begain in October 2022. Planning is underway to continue to the project grow even further in 2023.

Stakeholder Involvement:

Stakeholders were crucial to the successful implementation of the project, specifically within three realms: (1) Working with the coroner to access the list of deaths by suicide; (2) Working with the Behavioral Health Leadership Coalition-Data Sharing Collaborative (DSC) to implement the project; and (3) Working with an analyst at Douglas County to complete a crosswalk of LDCPH patients that presented at the Emergency Department with suicidal ideation. Each aspect of the project required stakeholder buy-in and work.

Primarily, a Senior Analyst at LDCPH worked closely with the Coroner to access a list of deaths by suicide within Douglas County. In Kansas death certificates cannot be utilized for this type of project. However, data from a coroner is publicly accessible and can be utilized primarily through autopsy reports. In Kansas, the coroner is not required to follow HIPAA and autopsies are not considered medical records. Even though it is legally accessible data, many agencies were understandably concerned about accessing it for fear of breaking patient confidentiality. This required the LDCPH Senior Analyst to engage in education and conversation to gain buy-in from the other agencies, primarily through the use of Confidentiality Agreements. It also required working closely with the coroner's office to assure they understood the intent of the project and for them to be able to provide the data in a timely manner.

Once it was determined that it was legal to access a list of deaths from suicide through the coroner, member agencies of the BHLC-DSC had to buy into completion of the data review. Beyond buy-in from the agencies, there were legal questions in this stage of the process that LDCPH worked to provide an answer. Questions included: (1) Can agencies share findings with public health? (Yes) And (2) Is anything on the list considered private patient health information?  (No). It was determined that agencies can share whether they saw anyone on the list and how many people they saw. They cannot share who they saw. Once this was determined, each agency was asked to complete the review of the suicide list.

Participating member agencies in the project represented by the BHLC-DSC include: LDCPH, the community mental health center, the local hospital, the local Federally Qualified Health Center, and two treatment and recovery centers.

The final aspect of the project requiring stakeholder involvement and collaboration was the crosswalk of LDCPH patients and patients seen at the Emergency Department for suicidal ideation. The source of data for this aspect is an integrated data sharing system that is managed and maintained by Douglas County. Informed consent is required for patients within the system, because their profile will be shared across agencies with shared clients. Agencies can enroll within the system to track utilization of services from their clients across the system of care. This part of the project required working closely with an analyst at Douglas County in order to access the data in a manner that allows for system-level analysis and the development of the case studies.

LHD Involvement:

LDCPH leveraged skillsets in data analysis, partnership building and collaboration, and systems-level thinking to serve in a Chief Health Strategist role for the behavioral health system to complete this project.

As previously mentioned, the LDCPH Senior Analyst had to work closely with KSPHQ and other subject matter experts to determine that all stages and aspects of the project were within legal statute and worked to provide the expected level of confidentiality and data sharing use to obtain buy-in from partner agencies and assure continued collaboration. Following this determination, work needed to be done to gain buy-in from partner agencies.

In order to facilitate progress on shared goals, the Data Sharing Collaborative meets monthly. The meeting is led by LDCPH. This was an opportunity to share progress on the project, challenges encountered, and lessons learned. It also allowed for the state suicide prevention agency (KSPHQ) to meet regularly with the local agencies and provide subject matter expertise.

This was not the first project completed by the BHLC-DSC. There are many community initiatives and projects being worked through the group. However, this was one of the first projects that tested the ability of the agencies to begin engaging in sharing data across the system of care to begin to make system-level progress on challenging public health issues. The ability of the group to complete the project shows the commitment to begin making progress on data sharing, even though this is extremely challenging within the behavioral health system due to privacy issues from both HIPAA and 42 CFR requirements.

Members of the BHLC-DSC represent people with lived experience with the negative affects of suicide.

Start-up Costs:

Costs identified with the project are minimal and are primarily identified as in-kind, specifically from staff time.

Identified LDCPH staff for participation in the project include:

·       Senior Analyst (approximately $70,000 annually): 1.0 FTE dedicated to a wide variety of projects, not just Zero Suicide. She dedicated the most time to the project, approximately 0.3 FTE worth of time. She served as the project designer and lead. She led most of the coordination among agencies and worked closely as a lead with Douglas County, Kansas Suicide Prevention HQ (KSPHG), and the Coroner.

·       Quality Improvement Coordinator (approximately $60,000 annually): 1.0 FTE dedicated to a wide variety of projects. Approximately 0.2 FTE time spent towards Zero Suicide. She served on the LDCPH Zero Suicide implementation team and worked closely with the Senior Analyst and Registered Nurse to provide a Quality Improvement lens to the project.

·       Registered Nurse (approximately $30 per hour): 1.0 FTE dedicated to working in nursing clinic, specifically lab support and within the medical record system. She assisted with reviewing the coroner's list to look for any patients seen within the last 12 months. Then she worked closely with the Senior Analyst and the Quality Improvement Coordinator to perform QI on the care provided to look for opportunities for improvement.

Other agencies participating in the project dedicated in-kind support, as well. Member agencies of the BHLC-Data Sharing Collaborative provide identified staff to attend meetings and complete the objectives of the project. KSPHQ staff provided subject matter expertise and guidance for understanding the Zero Suicide framework. The Coroner worked with the Senior Analyst to meet the data request.

The Zero Suicide Framework is free to implement. LDCPH staff worked closely with Kansas Suicide Prevention HQ (KDPHQ), who provided in-kind training and subject matter expertise. All the materials and associated trainings have been offered for free, at least within the state of Kansas. There is a full-day Zero Suicide training that LDCPH have completed as part of the implementation process. This was offered for free and the only cost is in-kind staff time for completing the training

Re-stated Objectives:

Objectives of the project are as follows:  

·      Objective #1: Access list of Douglas County deaths due to suicide from the coroner. This objective is considered met. The Senior Analyst worked with the coroner to obtain a list of people who died by suicide in Douglas County. Two lists were received. One with deaths from 2020, 2021, and beginning of 2022. The second list contained deaths only in 2022. A third list is coming in January 2023 with the remainder deaths—if any—from 2022.

·       Objective #2: Share the list with agencies within the local behavioral health system through the Behavioral Health Leadership Coalition- Data Sharing Collaborative (DSC). This objective is considered met. The two lists obtained thus far have been sent out to participating agencies. Six agencies representing the DSC participated in the project: one community hospital, one Federally Qualified Health Center, one local public health agency, one community mental health center, one drug and alcohol treatment center, and one intensive care coordination center.

·      Objective #3: Ask organizations to share "Yes/No" to whether they have seen someone on the list within a year. This objective is considered met. Of the six participating agencies, four out of six reported seeing a patient on the first deaths by suicide list. The second list was sent out in October 2022, and LDCPH data gathering is currently on-going.

·      Objective #4: Agencies perform a QI exercise regarding practices surrounding the service to determine if suicide was preventable. This objective is considered partially met. The LDCPH Senior Analyst worked with the QI Coordinator and a Registered Nurse to review the list and do a Quality Improvement review of the services provided to the patient. This has led to additional work being done by LDCPH to further implement the Zero Suicide framework internally. Other agencies have been asked to complete similar QI reviews.

·       Objective #5: Share general lessons learned with other agencies without compromising personal health information. This objective is considered partially met. Agencies within the Data Sharing Collaborative deploy a high degree of discernment when it comes to sharing information that could potentially violate patient privacy. The collaborative is currently in a conversation to determine the best and safest way to engage in these discussions without risking confidentiality.

·       Objective #6: Work with the county's data sharing system to perform QI on high-risk suicide patients to construct case studies. This objective is considered met. LDCPH and Douglas County analysts worked together to identify a list of patients from LDCPH that were seen at the Emergency Department for suicidal ideation. From this list, five case studies were developed with the goal of reviewing and improving the pathways of care for suicide prevention for patients.

For this project, most objectives are considered met. The ones that are not met have some degree of progress made.

Data Sources:

The main primary source of data used for the project are the list of deaths by suicide received from the coroner. Thus far, LDCPH has received two lists, and a third is coming in January 2023 with the remainder of the 2022 deaths. The lists, which are created based upon autopsy records, have the names of people who died, their date of birth, and the date of death. LDCPH compiles the list and sends it to participating agencies.

The first list had 33 names on it: 16 deaths from 2020, 14 deaths from 2021, and three deaths from 2022. It was sent out to the DSC agencies for their review in May 2022.  The second list had eight deaths on it all from 2022. It was sent in October 2022.

The second part of the quality improvement project—the development of the case studies—utilized two primary sources of data: the patient list from LDCPH and data from the integrated data system maintained by the county and primarily utilized for case management, called MyResourceConnection (MyRC). The LDCPH Senior Analyst worked closely with the Douglas County analyst to create a filtered list of LDCPH patients that were seen at the Emergency Department with suicidal ideation. (MyRC requires informed consent from the patient prior to being uploaded into the system.) The filtered list was used to create a series of case studies with the goal of increasing knowledge regarding the system of care.

No secondary data sources were utilized as a part of this project, except as part of the Community Health Plan metric related to suicide mortality rate. The secondary data source for this is the suicide mortality rate per 100,000, which is accessible via Kansas Health Matters from state death certificate data.

Performance Measures Used & Process/Outcome Measures:

Guiding the direction of behavioral health work in Douglas County is the Community Health Plan (CHP), specifically the behavioral health plank. The overall suicide mortality rate is a key metric for the behavioral health work. Over the past couple of years, the suicide mortality rate has declined from 17.1/100,000 in 2013-2015 to 15. 2/100,000 in 2018-2020, but the rate is still above the stated goal of 14.0/100,000. It is too early to discern if this project will affect the suicide mortality rate.

Increased Knowledge:

One result is the increased knowledge regarding data sharing within both the local Douglas County system of care and the overall Kansas system. Locally, the Data Sharing Collaborative has been working together in partnership for many years to determine best practices for data sharing to improve access and care. This study was a test case for beginning the process of data sharing within the system to improve practices for suicide prevention. Many legal and data challenges were worked through to get to a place of comfort with the project among the agencies. The collaborative is now looking at ways to build upon the project and expand even further.

Additionally, as the LDCPH Senior Analyst worked closely with representatives from the state-level suicide prevention agency (KSPHQ), the knowledge from the project has the potential to be disseminated state-wide. This is already beginning to occur as the Senior Analyst co-presented with KSPHQ regarding the results of the study at the Kansas Prevention Conference.

Internal Process Improvement:

As a result of the work done around Zero Suicide, many internal processes have either been improved upon or implemented that enhance our health department's capacity to engage in the framework with a high degree of fidelity.

·       LDCPH Zero Suicide Implementation Team developed with members representing a diversity of programs started meeting on a regular basis.

·       Development of process to complete a QI review of processes surrounding suicide cases who were identified as previous patients.

·       Receipt of a Zero Suicide grant from the state health department to further implement the framework.

·       Mental Health First Aid training offered for any interested staff.

·       Zero Suicide Organizational Assessments scheduled for direct patient care programs.

·       Identification of a part-time staff member to provide follow-up care for patients that have been referred for behavioral health services.

Results Analyzed:

Organizations were asked to report to LDCPH a ‘Yes/No' as to whether they saw someone on the list and, if yes, the number of people they saw one year prior to their death. As a reminder, it is legally allowable for agencies to share with public health whether they saw someone on the list and how many people they saw, but not who they saw.

For the first list, four out of six participating agencies reported to public health that they saw someone. Two of the agencies claimed that they saw 6% of the people on the list; and one agency reported that they saw one person on the list. The other agency reported ‘Yes' to having seen someone on the list but declined to say how many people.

The follow-up list was sent out in October 2022 with an additional eight deaths on it. LDCPH is still awaiting responses from all agencies for their review of the list, but thus far three of the six agencies report having seen someone on the second list. Agency #1 reported seeing two out of eight deaths; Agency #2 reported seeing five of the eight deaths; and Agency #3 reported seeing nine out of 41 (41 is the total number of deaths from both lists combined).

This information is beneficial from an internal quality improvement perspective and helpful as a test case in data sharing. However, the limitations of the study are apparent within the results. Since the agencies all report their data and results differently and public health is unable to match patients, it is difficult to make broader, system level interpretations. This has led to the development of a follow-up study which hopes to understand these linkages and is discussed more in the Sustainability section.

For the LDCPH and suicidal ideation at the Emergency Department portion of the study, LDCPH worked to complete a crosswalk of patients between the two settings. Due to the nature of COVID immunizations and testing (specifically that they are quick with limited patient-provider interactions), it was decided to exclude COVID tests and vaccine LDCPH encounters. Five case studies were developed.

Case Study #1: ED visit following LDCPH visit for STI treatment; referred for substance abuse, mental health, and housing follow-up. Presented with ideation seven months later.

Case Study #2: ED visit one month prior to LDCPH visit. Screened positive for depression on PHQ2 at LDCPH.

Case Study #3: ED visit prior to LDCPH visit. Presented at LDCPH for HIV testing; no screening performed.

Case Study #4: ED visit after LDCPH visit. TB screening as part of visit at a detention center.

Case Study #5: ED visit on same day as LDCPH visit. Patient left ED after receipt of mental health diagnosis and comes to LDCPH. LDCPH refers to community mental health center, but patient insists they are fine. Follow-up ED visit two days later with ideation.

The case studies were developed to provide opportunities for learning for the collaborative, but also for process improvement for LDCPH around suicide prevention. Strengthening the referral process has been a process identified for improvement.

Practices Change as Result:

The result of the review of the lists of deaths by suicide has been increased discussion in the local Zero Suicide Community of Practice group for agencies to begin sharing lessons learned and challenges from their internal quality improvement efforts in a confidential way. This discussion has not yet occurred, but considering the conversation is even occurring is a demonstration of how far the collaborative has come in terms of trust for data sharing. The fact that the group is wanting to work towards active sharing of lessons learned from a QI perspective is considered a win!

The project has led to lessons learned and improvements made for data sharing among partner agencies. Lessons learned include and practices enhanced include:

·       Speak to common concerns that agencies have regarding how identifying information is used within the healthcare sector and how it legally falls within current statute and regulations.

·       State clearly the intentions for the data through regular communication, answering of questions, and clearly outlined goals and objectives.

·       Use written expectations and standards to communicate how the data will be used.

·       Develop confidentiality forms. This allows the agencies to see in full the details of the project and allow for an easy method for legal departments to sign-off on the project.

Specific to the last point: even though the Zero Suicide Quality Improvement project was well within the bounds of current statute, the LDCPH Senior Analyst took extra steps to develop and distribute a confidentiality form for all participating agencies. The confidentiality agreement clearly and concisely outlined the intent of the project, why it was important, and the exact parameters and scope of the project. Each agency was asked to review the confidentiality agreement and return it to LDCPH. The extra step in legal and administrative sign-off on the project led to increased agency comfort in participating in the project.

Fiscal Sustainability:

The project has a high degree of sustainability due to minimal start-up costs and the utilization of a pre-existing coalition to serve as the partner agencies.

The Data Sharing Collaborative of the Behavioral Health Leadership Coalition existed prior to the implementation of this project and it seems likely to continue beyond this project. The DSC, which is primarily comprised of the analysts from the member organizations, meets monthly to discuss a variety of behavioral health and data sharing projects. The group has been meeting regularly for years at this point. The DSC meetings are led by an analyst from LDCPH. Commitment to the DSC from participating agencies remains strong.

Additonally, partnership with the state-wide suicide prevention agency, Kansas Suicide Prevention HQ, remains strong. LDCPH has already worked with KSPHQ to identify additional projects and trainings to participate in for 2023, including a free Zero Suicide training in January 2023 that many members of LDCPH leadership will take. KSPHQ has assured LDCPH that they will continue to be available to provide subject matter expertise and consultation on process improvement.

As previously mentioned, the bulk of work on the project was completed as in-kind services through staff time. The Zero Suicide framework is free to access and implement and much of the advice provided by subject matter experts was provided in-kind. Start-up costs are minimal due and much of the work is highly collaborative in nature.

The work done through this project has opened up additional funding opportunities for LDCPH. LDCPH was able to apply for and receive a $50,000 Zero Suicide grant from the state health department, in part due to the strength of application based on this work. It is conceivable that as deaths due to despair rise as a public health issue of concern, additional opportunities for funding will be available. The grant also assures LDCPH's commitment to further implementation of the Zero Suicide framework internally.

Douglas County provides funding to LDCPH to support behavioral health and data initiatives as part of the city-county funding agreement and this support has been budgeted and approved through at least 2023. The work of this project assures the county that LDCPH is utilizing funding for behavioral health work in an appropriate way with demonstrable results.

The positions for the QI Coordinator, Senior Analysts, and Registered Nurse are all budgeted through 2023. The LDCPH Zero Suicide Implementation Team is in-place for 2023 and is anticipated to continue to meet regularly. Another Zero Suicide training is currently scheduled for January 2023 and additional staff are completing Mental Health First Aid training in winter 2023. 

A cost/benefit analysis was not completed as part of the project.

Future Projects from Lessons Learned:

Lessons learned from the initial project have led the group to further enhance the study to be able to make more system-level interpretations. From the work of the initial project, the collaborative has learned that from 2020-2021 four of the six agencies participating in Zero Suicide have seen at least one person in their agency within a year of their death from suicide. However, further information or knowledge about the system of care is limited at this time.

To address these gaps, the LDCPH Senior Analyst has designed a project that will further enhance the data sharing and capacity to make system-level interpretations. LDCPH administrative staff and legal contractors have signed off on the project and agencies from the DSC have also signed-off on participation. Furthermore, the new project would enlist assistance from the University of Kansas by utilizing a data repository and an analyst from KU who would blind the data to allow for systemic interpretations without revealing personal health information or patient confidentiality. The data repository at KU has already been built as part of an earlier data sharing project between KU and the Data Sharing Collaborative.

The goal of the proposed project would be to answer the following questions:

1. What % of people who die of suicide in Douglas County were seen by a Zero Suicide Agency in 2020?

2. What % of people who die of suicide in Douglas County were seen by a Zero Suicide Agency in 2021? 

3. What % of females who died of suicide in 2020 and 2021 were seen by a Zero Suicide Agency?

4. What % of males who died of suicide in 2020 and 2021 were seen by a Zero Suicide Agency?

LDCPH believes that the methods of this study will protect the anonymity of the people who died of suicide and even though the agency name will be known to KU, KU will not report data in a way that can identify any patient or agency. The project is slated to begin in 2023 and will hopefully continue to further our understanding of a healthcare system can be a leader in the prevention of suicides.