- A Zero Suicide Initiative at the Utah-based Intermountain Healthcare has underscored the importance of holistic, team-based care. Through integrated mental health and primary care, the health system has leaned on system-wide care coordination to address a mental health issue that looms over the state of Utah.
Between 1999 and 2016, Utah saw a 46.5 percent spike in suicide rates, according to the most recent numbers from the CDC. This makes Utah the state with the fifth-highest rate of suicide in the country.
Leadership at Intermountain observed this increase as well, and determined the system must tackle what it saw as a significant public health issue.
“In 2014 our clinical program really saw that suicide was a major problem, and we put together what's called a care process model,” Mark Foote, MD, the senior medical director for Intermountain’s behavioral health department, told PatientEngagementHIT.com in an interview. “We had a large group of interested parties come together and write out how we were going to deal with suicide and suicide prevention at Intermountain Healthcare.”
That workgroup created a new care process that foremost aimed to increase the number of mental health and suicide screenings its providers administered to patients. Using common mental health screenings, including the PHQ-2, the PHQ-9, and the Columbia Suicide Scale, the health network set out to move the needle on suicide rates in Utah.
“Over the last three years we've increased screening, but the suicide rate continues to rise,” Foote reported. “And as we have seen the suicide rate grow, and it being in headlines, and in the paper, and we see it with our own patients and our own practices, there was this sense that we needed to do more.”
Intermountain found that many of their goals were in line with the national Zero Suicide framework, first developed by the Henry Ford Health System.
“[Zero Suicide] is a culture shift away from fragmented suicide care toward a holistic and comprehensive approach to patient safety and quality improvement—the most fundamental responsibility of health care—and to the safety and support of the staff who do the demanding work of treating and caring for suicidal patients,” says the framework’s website.
With these common goals in mind, Intermountain to adopted the Zero Suicide framework, leaning on community health partnerships with the state to implement the program.
For its part, Intermountain has moved from offering a behavioral health program to delivering holistic, patient-centered care that takes into account a patient’s mental health status. Although Intermountain has been delivering integrated mental and primary care for over a decade, the new initiative works to supplement those efforts.
In addition to using its evidence-based mental health and suicide risk screenings, Intermountain has worked to bolster its integrated mental and primary healthcare. In doing so, the system hopes it can capture at-risk patients who fall through the cracks.
“The ‘captain’ of the delivery of care for behavioral services is still the primary care provider,” Tammer Attallah, MD, the psychology program director at Intermountain’s Primary Children’s Hospital, explained in a separate interview. “Then we have the support of a behavioral health specialist, that being either a psychotherapist, psychologist, or licensed clinical social worker. The team also has either an advanced practice nurse that has specialized in psychology or a psychiatrist.”
These mental health specialists are there to support the primary care provider, who is at the forefront of patient care, Attallah clarified. During the primary care appointment, the PCP is in charge of administering and assessing a patient’s mental health screening.
“There's a very systematic form or process that identifies people as either mild, moderate, or complex,” he added. “Mild cases may require some medication and some support for families. Some of the moderate cases may actually involve engaging the mental health provider that's actually embedded in the clinic to deliver some short-term evidence-based psychotherapy strategies as well as medication or psychotropic medication support.”
In complex cases, the primary care team hands the patient off to a tertiary, specialized care option within the Intermountain system. Timeliness of a warm handoff is essential, Attallah emphasized, because it increases the likelihood that the patient will actually see the mental health specialist she may need.
Screening for and delivering mental healthcare in the primary care setting has been key for overcoming some of the stigma attached to mental healthcare, Attallah said.
Patients tend to trust their primary care providers. When the primary care provider asks personal questions about mental health status, patients are more likely to answer truthfully. Additionally, patients are more apt to trust a referral from their primary care provider.
That is not to say primary care providers do not face a unique set of challenges caused by mental health stigma, Foote cautioned. When the PHQ-2 and PHQ-9 conclude with questions about suicidal thoughts, it is still often difficult for primary care providers to elicit candid responses from their patients. More work must be done to address the stigma surrounding suicide risk to keep at-risk patients from falling through the cracks.
Intermountain is working on improvements in other areas as well, Attallah said. For example, despite concerted efforts, primary care providers still are not administering the PHQ-2, PHQ-9, or Columbia Suicide Scale during 100 percent of appointments.
Are there tools within the EHR that makes it easier for providers to administer screenings? Will notifications help? Intermountain is looking for new mechanisms that will make the process more efficient.
Additionally, Intermountain is looking to leverage its position as an integrated delivery network – meaning they offer both treatment services and a health plan – to expand its Zero Suicide framework, according to Scott Whittle, MD, a child psychologist and the medical director of Intermountain’s Select Health plan.
“We've got just short of a million people who are insured by SelectHealth,” Whittle said in an interview. “We can make Zero Suicide possible for them, too. And the way to do that is to push the idea of effective screening, knowing the risk factors, having people trained to then pick up on information, and help people find their way into care. We must push it into other arenas.”
For example, Select Health’s product for large employers, called Share, has a program that incentivizes mental health screenings for beneficiaries. These incentives draw on the same goals within the Zero Suicide framework.
All of these approaches hinge on delivering patient access to care, each of the experts reported. Screenings are less helpful when patients are unable to connect with the care they now know they need.
And while connecting patients at the point of care through integrated primary and mental healthcare is helpful, challenges lay ahead with referrals and handoffs.
“For that, we have teams of people,” Whittle stated. “We have advocates who can receive a phone call and direct people to care. They'll be on the phone with the patient, set the appointment, and give the patient all the detailed information he needs to know to get to that appointment. We also have care managers who'll follow up on care access.”
At the end of the day, Zero Suicide requires a culture shift, Foote added. Intermountain can put in place every mechanism to flag patients at risk of suicide as well as tools for connecting to care. But patients may still be reluctant to access care so long as there is stigma in the way.
Intermountain is involved in a community and media outreach program to raise mental health and suicide awareness, hoping to normalize the issue and incent more patients to seek and accept help, Foote reported.
But it will also be important for providers – especially those in primary care – to embrace their roles in integrated care. Foote still observes issues with primary care providers who do not believe mental healthcare is within their scope of practice.
“We've had to go back and provide education,” Foote said. “If somebody came in and they had chest pain, the PCP would ask them about it. If the patient had chest pain that makes the PCP think it's cardiac in origin then you need to put a risk level on it. And if doctors are really concerned that this chest pain is cardiac, then they’re going call an ambulance. All of this happens even if the patient had been coming in to see the doctor about a dermatology problem.”
This must be true of mental health, as well, Foote said.
What’s more, this norm must extend to the full care continuum. Addressing a widespread problem like an increasing suicide rate will require team-based focus, Foote explained.
“This is all of our problem,” he asserted. “This is a public health crisis, and we have to continue to confront stigma that comes up by giving data and examples and the facts. We must also be giving stakeholders something to do about it, and that oftentimes involves improving our access. Then, providers are okay with asking mental health questions because they know they have a place to send patients.”
Whittle expressed similar sentiments, saying that by raising awareness and erasing stigma, the medical industry can indeed achieve its Zero Suicide goal.
“We've treated behavioral health as if it's unmanageable and stigma is a big part of that,” Whittle concluded. “Combating that stigma and treating suicide like the healthcare condition that it is and using the evidence-based approaches within the framework, we can actually achieve Zero Suicide.”