National Suicide Prevention Efforts for Veterans: The Role of the VISN 2 Center of Excellence for Me

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National Suicide Prevention Efforts for Veterans
The Role of the VISN 2 Center of Excellence for
Mental Health and PTSD at Canandaigua

• Kerry L. Knox Ph.D.
• Director
• VISN 2 Center of Excellence at Canandaigua
• Associate Professor, University of Rochester
• Jan Kemp, Ph.D.
• Associate Director Education and Training
• VISN 2 Center of Excellence at Canandaigua

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VISN 2 Center of Excellence for Mental Health and
PTSD at Canandaigua

• Meet the Faculty and Staff

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VISN 2 CoE by Design

• The VISN 2 CoE was officially announced August
  2007
• There are currently 47 projects in process.
• 41 people involved in projects at present.
• Responsibilities
• We are a National Resource to VA Central Office
  on establishing new initiatives and guidelines
  for suicide prevention for veterans
• We are a partner in many projects in VISN 2and
• We live at the Canandaigua VAMC and collaborate
  closely with the Department of Psychiatry at the
  University of Rochester, and all CoE have faculty
  appointments in the Department

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VISN 2 CoE by Design
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Epidemiology and Health Services Research Core
Key Research Questions

• What is the impact of broadly based, universal
  suicide prevention efforts on rates of attempted
  suicide, suicide, depression, PTSD, and other
  relevant outcomes at a population level?
• Is access to care at a population level improved
  through novel suicide interventions and
  strategies?
• Are there new, emergent veteran populations at
  risk for suicidal behaviors?
• What is the epidemiology of veterans outside of
  VAs walls?

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Clinical Interventions Research Core Key
Research Questions

• Are treatment strategies that target behavioral
  change in selected and indicated populations
  effective for veteran populations?
• What are the most effective means of
  disseminating new knowledge to the field
  concerning evidence based/best practices of
  behavioral interventions?
• Does the application of CAMS or MI increase the
  probability of reducing suicidal events following
  intervention with a behavioral intervention (such
  as CBT) through improving client compliance?

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Education and Training Core Key Programmatic
Activities

• Education and Training Core
• Ongoing education and training of clinical staff
  for VAs 24 hour Suicide Crisis Line
• Ongoing education and training of VAs network of
  Suicide Prevention Coordinators
• Development of Training Manuals for Enhancing
  Clinical Management of Suicidal Veterans
• Dissemination of new knowledge to the field
  concerning effectiveness of behavioral
  interventions provide support in terms of
  training as needed to the field

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Epidemiology and Health Services Research Core
Current and Developing Studies

• Knox KL, Kemp J. Epidemiology of Callers to VAs
  24 hour Mental Health/Suicide Crisis Line
• Knox KL, Kemp J. Outcomes and Referral Patterns
  of Callers to VAs 24 hour Mental Health/Suicide
  Crisis Line
• Lavigne J, Crilly J, Homifer B, Kemp J, Knox KL.
  Effectiveness of VAs 24 hour Mental
  Health/Suicide Crisis Line
• Crilly J, Lavigne J, Homifer B, Kemp J, Caine ED,
  Knox KL. Treatment trajectories of VA service
  connected veterans versus non VA service
  connected veterans who call VAs 24 hour Mental
  Health/Suicide Crisis Line

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Epidemiology and Health Services Research Core
Current or Developing Studies

• Lavigne J, Berndt E., Saweikas M, Knox KL
  Post-launch pharmacosurveillance for suicide for
  smoking cessation and anti-seizure drugs (in
  collaboration with Fran Cunningham and Marcia
  Valenstein)
• Lavigne J, Knox KL. Handgun use and other risky
  behaviors in veterans during life transitions
• Conner K, Ilgen M. Development of a uniform
  suicide related assessment form for VAs Suicide
  Prevention Coordinators
• VonBergen H, Kemp J, King D, Knox KL. Operation
  S.A.V.E. Evaluation of suicide prevention guide
  training for front-line VA staff and communities
  (Veterans Service Organizations and non VA
  organizations such as NYS OMH, chaplains, social
• services)

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Epidemiology and Health Services Research Core
Current or Developing Studies

• Knox KL, Kemp J., Lavigne J., Crilly J. Validity
  and reliability of the suicide behavior reporting
  template by Suicide Prevention Coordinators
  across all VA networks
• Knox KL, Chauncey L, Chitaphong K.
  Identification of veterans outside the walls of
  VA Who and where are they?

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Clinical Interventions Research Core Current or
Developing Studies

• Pigeon W, Matteson S, Pratt M, Chauncey L. Knox
  KL. Cognitive behavioral treatment for insomnia
  in Vietnam veterans
• Pigeon W, Matteson S, Pratt M, Chauncey L. Knox
  KL. Cognitive behavioral treatment for insomnia
  in returning OEF/OIF veterans
• Conner K, Britton P, Currier G. Proximate risk
  factors for suicide in veterans with substance
  use disorders
• VonBergen H, Kemp J, Knox KL, Caine ED.
  Implementation of CAMS following training
  clinical staff in VISN 7.
• VonBergen H, Kemp J, Knox KL, Caine ED.
  Implementation of MI following training clinical
  staff in VISN 2.

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Clinical Interventions Research Core Current or
Developing Studies

• Conner K, Britton P, Currier G. Use of
  motivational interviewing (MI) in treatment of
  suicidal veterans with SUDs
• Conwell Y, Richardson T, King D, Duberstein P.
  Pilot study of identifying elder veterans seeking
  care through a community ED for a mental health
  problem or suicidal behaviors

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Clinical Interventions Research Core Current or
Developing Studies

• Conner K, Britton P, Currier G. Use of
  motivational interviewing (MI) in treatment of
  suicidal veterans with SUDs
• Conwell Y, Richardson T, King D, Duberstein P.
  Pilot study of identifying elder veterans seeking
  care through a community ED for a mental health
  problem or suicidal behaviors

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Education and Training Core Current or
Developing Programs

• Ongoing education and support for VAs network of
  Suicide Prevention Coordinators
• Ongoing education and support for VAs 24 hour
  Mental Health/Suicide Crisis Line
• Dissemination of training for Operation S.A.V.E.
• Dissemination of training for CAMS and
  Motivational Interviewing as a demonstration
  project in VISN 2 and VISN 7

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Ongoing VA National Initiatives

• VAs 24 hour Mental Health/Suicide Crisis Line
• VAs Network of Suicide Prevention Coordinators
• Patient Record Flag
• Provide information and guidance for VA National
  Policy

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Scientific Consensus Conference Development Core

• Knox KL, Kemp J., Currier G, Conner K, Conwell Y,
  Caine ED. Developing guidelines for suicide
  assessment instruments across VA sites and
  populations March 5-6th 2008
• Currier G, Knox K, Kemp J, Conner K,Caine ED.
  Evidence based/best practices for treatment of
  suicidal individuals (Early Fall 2008)
• Currier G, Knox K, Kemp J, Conner K,Caine ED.
  Evidence based/best practices for treatment of
  high risk, non suicidal individuals (Late Fall
  2008)
• VonBergen H, Knox K, Chitaphong, Kemp J, King D,
  Caine ED. Collaborations with community
  organizations and institutions to identify
  OEF/OIF veterans not accessing mental health care
  in the VA (Winter 2009)

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Specific Activities related to VAs Initiatives

• Suicide Prevention requires ready access to high
  quality Mental Health Services, supplemented by
  programs that address the risk of suicide directly

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Enhancing Access to High Quality Care

• Implementation of the MH Strategic plan with
  support of the Mental Health Initiative
• Enhancing mental health services
• at community based clinics
• through integrated care models
• Increased MH coverage in Emergency Departments
• Facilitating transition to VA for returning
  veterans
• Accelerating access for new patients through new
  initiatives
• Expansion of recovery/rehabilitation services as
  keys to hope for patients with serious mental
  illness
• Disseminating evidence-based psychotherapies

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StructureSpecific Activities for Suicide
Prevention

• Centers of Excellence
• National programs for education and awareness
• 24 / 7 Hotline
• Suicide Prevention Coordinators in each medical
  center

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Suicide Prevention Coordinators

• Each VA Medical Center has or is in the process
  of hiring a Suicide Prevention Coordinator (SPC)
• Overall responsibility is to support the
  identification of high-risk patients and to
  coordinate ongoing monitoring and enhancements in
  care.
• Other responsibilities
• Promote awareness and community outreach
• Training both for provider and Guides
• Flagging patients at high risk
• Tracking and monitoring high risk patients and
  their care
• Participation in patient safety and environmental
  analysis to develop local suicide prevention
  strategies

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Processes Hubs of expertise in suicide
prevention

• Provide technical expertise to the field
• Develop training and educational materials and
  programs for a wide range of providers, staff and
  community partners
• Conduct research and quickly disseminate findings
  to the field for implementation
• VISN 19 MIRECC Clinical approaches
• VISN 2 COE Public Health approaches

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ProcessesEducation and Awareness

• Collaboration with Employee Education Service for
  conferences for clinicians, Satellite broadcast
  programs and web-based education programs
• Designation of VA National Suicide Prevention
  Awareness Day
• VA Guide Training a program developed to
  educate all VA staff as well as those in the
  community who have contact with veterans about
  risks of suicide, warning signs, and facilitating
  care.
• Clinical training programs
• General clinical training in development
• Emergency room providers April 24th
• Suicide Risk Assessment Pocket Cards and
  Reference Guide
• CBT demonstration projects

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ProcessesEducation and Awareness cont.
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ProcessesFocus on Patient Safety

• Environmental scans in closed inpatient units
• Enhanced staff coverage in residential care
  facilities

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ProcessesScreening and Triage

• Patient screening for MH conditions is being
  followed by evaluation of suicide risk in those
  who screen positive
• Pending requirement for evaluation of new
  patients within 24 hours of a referral/request
  for MH services, including evaluation of danger
  to self or others

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ProcessesTracking and Monitoring

• Development of a template to guide the
  identification of patients with suicide
  behaviors, and to ensure monitoring and follow-up
• Development of a national patient alert system so
  that all providers are aware and are cued to
  address high-risk patients needs.
• Monitoring suicide rates to identify national,
  regional, and local risk factors as well as trends

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ProcessesFacilitating evidence-based
treatments

• Cognitive Based Therapy
• Planning for dissemination of pharmacological
  strategies
• Other site specific projects including
• Interpersonal Therapy
• Dialectical Behavioral Therapy
• Collaborative Assessment and Management of
  Suicidality
• Motivational Interviewing

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ProcessesVeteran Suicide Hotline

• In conjunction with the national suicide
  prevention hotline number 1-800-273-TALK.
• VA option will direct Veterans to a VA
  professional who will immediately address their
  crisis situation.
• Hand-off to local Suicide Prevention Coordinators
  for follow-up and assurance that these veterans
  in crisis receive on-going care
• Use of hotline calls to
• engage veterans in MH care,
• trigger intensifying care
• allow program-solving about difficulties in care

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VA National Suicide Hotline
CALLS to HOTLINE July 07 March 08 Total
calls 37,237 Indentified as Veterans
13,746 Identified as being concerned about a
veteran 1668 Warm transfers 1860 Active Duty
409 Total Rescues 726
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CALL OUTCOMES

• SPC Referrals 2180
• Types of Referrals
• No Contact - unable to find veteran or veteran
  chose against 151
• Immediate Evaluation at VA or CBOC provided
  207
• Admissions 383
• Enrollments 68
• Ineligible and referred to community services
  66
• SPC contacted caller and arranged for
  appropriate care 1963
• Referral to VA Services (OIF/OEF program,
  substance abuse program, homeless program, given
  SPC ) 849
• SPC contacted caller who refused care -
  information about VA given 66
• Rescue provided - No F/U desired 97
• Rescue provided with F/U arranged by SPC 408

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Suicide prevention is everybodys business