Hear from experts about pragmatic implementation strategies for the primary care setting, including one practice’s key lessons learned from putting them into action. Panelists in this Moving Medicine episode include Virna Little, PsyD, LCSW-r, SAP, CCM, Daniel Miller, MD and Allison Dubois, MPH. Learn more about the BHI Collaborative Overcoming Obstacles Series.
- Virna Little, PsyD, LCSW-r, SAP, CCM, COO & co-founder of Concert Health
- Daniel Miller, MD, chief of GME & Behavioral Health Integration, Sun River Health
- Allison Dubois, MPH, executive VP & COO, Sun River Health
- Todd Unger, chief experience officer, AMA
Dr. Little: So we really want to make sure that we’re creating organizations and practices that feel comfortable talking about suicide and creating an atmosphere where patients can and do feel comfortable talking about suicide.
Unger: That’s Dr. Virna Little, chief operating officer and co-founder of Concert Health, a national organization providing behavioral health services to primary care providers. In this episode of Moving Medicine, our expert guests share ways to address suicidal ideation within the primary care setting, including ways for physicians to foster an environment of comfortability for patients to better treat this increasing phenomenon. In addition to Dr. Little, our guests include Dr. Daniel Miller, a practicing family physician and the chief of Graduate Medical Education and Behavioral Health Integration for Sun River Health, as well as Allison Dubois, executive vice president and chief operating officer for Sun River Health. Here’s Dr. Little....
Little: Great. I'm really glad to be here today along with my colleagues to talk about suicide prevention and primary care, and to hopefully really give some ground rules or guidelines for primary care clinicians and leaders in practices and tips that they can take back immediately to their organizations and their practices. So firstly, to really ground us in thinking about the rates of suicide, one of the things we know is that we've seen some decreases in some of the chronic illnesses. But suicide, pretty consistently around the country, has been increasing particularly since the pandemic around a lot of social determinants, a lot of people feeling very disconnected. And so it is certainly very likely that many of the patients you see will be thinking about suicide. Some of them will have thoughts about how they might die by suicide, and some of them may even have made a suicide attempt.
So we really want to make sure that we're creating organizations and practices that feel comfortable talking about suicide and creating an atmosphere where patients can and do feel comfortable talking about suicide.
So I always like to ground everyone around language. You heard me say, died by suicide versus committed suicide. People commit crimes, they die by suicide. So really making sure we're using the right language to help people feel comfortable. Also really trying to avoid language like successful or unsuccessful attempt. I often talk about the time when I was in an emergency room and had a 13-year-old introduced to me who had tried to die by suicide that morning. And they said, here's so-and-so, she had an unsuccessful attempt this morning. So the message that we send is first, you can't even die successfully and second is, had you been successful, you would not be with us.
Also trying to really describe behavior and not to use words like "manipulative" or "attention seeking." I often get the opportunity to review charts, and we'll see language in the electronic health records and charts or sometimes in patient flags. "Patient is manipulative, patient is attention seeking," oftentimes in capital letters. And one of the things that we want to try to do is not pretend to know someone's intention. I don't pretend to know someone's intention but what I do know is that if someone is talking about suicide, they're more likely to die by suicide. So I really just like to start there.
Also, it is way more helpful to really describe what someone said or did. If I see a patient and then Dr. Miller sees the patient after me, it's much more helpful for him to know exactly what that patient said or did than for me to describe the patient as attention seeking. We also want to use words like "diagnosed with' or I prefer "caring for" as opposed to "dealing with." And that someone is diagnosed, so in other words, it's not that they're a "borderline person," that they're "diagnosed with borderline" as an example.
So one of the things we're going to try to talk about today is the role of primary care and suicide safer care. What we can do to identify people, how we can do some assessment and some safety planning, and most specifically, things that we're able to do right in the primary care office to be helpful for patients that are at risk for suicide.
So why are we focusing on health care settings? So a couple of reasons. Many of you probably have heard the research around most of the people who die by suicide saw their primary care provider in the month of death. We also know from some later research that patients who have been disconnected, in other words, not connected to any care, health or mental health, will actually resurface in primary care during the month of death for an average of two visits. And that was actually from a payer who did a very large review.
And so it's really interesting to think about people who resurface in primary care. We also know that people who are at risk for suicide will use the portals more. So oftentimes, you will see an increased portal usage in their primary care offices. But most importantly, most people who are really in suicide prevention and who are working hard to make sure that the suicide rates go down, we're all under the same thought that it's really going to be difficult unless we engage primary care or something different happens in primary care.
So one of the things we know is that many of the regulatory organizations, such as Joint Commission, are really saying, listen, we need to have a way to care for people at risk for suicide. We need to have systems in place. We need to be thoughtful as an organization.
And so as you're listening, you want to start to think about ways that you can address suicide care in your practice and in your organization. So one of the most common ones that I will often see is that we don't often share patients who are at risk for suicide, we don't share that information with our front desk staff as an example.
So we had someone die by suicide one time, and they called and they canceled the primary care appointment, they canceled the specialty appointment, they canceled the behavioral health appointment during a short period of time. And nobody who answered the phone knew that person was at risk to do anything different, and there was no system in place to know that this person had canceled three appointments in a short period of time.
I often hear places like billing, where we want to make sure that if someone makes a suicidal statement, people know what to do. And so really encourage you to think about places in your system where people might be falling through the cracks.
And as you go forward and think about suicide,say for care in your organization and in your practice, I encourage you to go to the Zero Suicide website. It has lots of interesting CME activities, safety planning, assessment toolkits that you can use for your practice and your organization. So if you haven't had a chance to go to the website, I encourage you to do so.
So oftentimes, when we've been going around to primary care practices, and there's a large project it was actually funded by Centene in conjunction with the Association for Clinicians for the Underserved, where we've had the opportunity to go around to about 3,000 primary care providers and their teams in 28 states. And we've heard lots of different things.
One thing we heard which didn't surprise me at all is that most providers said, hey, yeah, it's actually part of what I really think I need to do is to care better for people at risk for suicide. They saw themselves as playing a role and being an important part of keeping people safe.
The other thing we heard is that most people and most providers didn't have any training either in their training program or in their current organization. And so we oftentimes heard, I don't have the knowledge to really know what to do. And so what we tried to do is to think of ways that we could help frontline providers in terms of knowing what to do.
So many times what we hear from someone who is at risk for suicide is they might answer yes to a depression screening, which we'll talk a little bit about. But certainly, what we know saves lives the most is hope. And what people need is hope. And anyone, regardless of their role on the primary care team, their background, their credential, can give someone hope.
So what we like to do is talk to practices and providers about what I like to call storage statements. So storage statements are some things that we've thought about ahead of time that we can respond to someone who maybe just told us for the first time that they're thinking about suicide.
And I don't know about you, but I know that I've had times in my life where I've told someone something for the very first time, and that first couple of seconds and their initial response really dictated to me, am I sorry I told them? Do I keep talking? Will I ever tell anyone else? And so for many patients, it's the first time that they've talked to someone about their thought of suicide. And that initial response can really determine whether or not they feel comfortable talking about their suicidal thoughts.
And so oftentimes, I like to think about, well, what do we want someone to know that just told us that they're thinking about suicide so that we can think about what we might like to say? And so often, what we want to say is thank you for telling me you're thinking about suicide. I heard you. And we want to say the word, suicide, right? We want to talk about what we need to talk about.
Thank you for telling me you're thinking about suicide. You're really important to me. Your life matters to us here at the center. You're really important to me. Your life matters to us here at the practice. So you really matter to us.
And we also want to make sure that what we do is that we make sure to let someone know, I have hope for you. I can see how strong you are. And so it's often important to practice those storage statements, two or three sentences. So maybe tonight when all of you are brushing your teeth, it's helpful to think about, what are two or three sentences that I could say if someone tells me that they're thinking about suicide? And I've had providers come back and say, gee, I didn't do it. But then I had someone in my office, and I'm really glad that I remembered yours.
The second thing that we often hear is there's not enough time. Like, I don't have time to do anything about this. And so I will often tell a story about my husband who went into primary care with some hearing loss. And they took his height and his weight and his blood pressure. And after his blood pressure, the medical assistant left the room.
And so a couple of minutes later, the primary care provider comes back in, and she takes his blood pressure. And she says, listen, your blood pressure is through the roof, and I'm really concerned about you. I don't think that you're able to go home today. And she asked him some questions about what was going on and medications. And said, listen, OK, what I'm going to do is I'm going to go see another patient, and I'm going to come back, and we're going to figure out what to do. So we didn't talk about the original reason we had gone again during the visit, because it wasn't the most important.
And so certainly, we do this all day long in primary care. I think Dr. Miller will talk about a little bit later today about how it would be a beautiful day in primary care if everyone came in for one thing, and it was exactly what they came in for. It turned out to be the most important. It almost never happens in primary care, and so we do this all the time.
So our job is to really make sure we know what's going on with someone, we come up with an appropriate level of care. If everyone who came in with asthma, what happens? They come in, we might give them a treatment, we talk to them. We make sure, maybe we talk to them about how they use their rescue inhaler, what's going on at home? Are there emotional triggers? Are there environmental triggers? We might give them some education about how to use their space or we do an asthma action plan. We might even send someone to the home to see if there's anything environmental in the home that's a problem. We do this all the time.
And so whether or not someone has asthma or elevated blood pressure or suicide risk, we stop, we get the information, we do some assessment, we do some safety planning, and we put an appropriate level of care in place. So I can't think of anyone that does this better than primary care.
So what we want you to do is we don't want anyone to panic. We want you to have your storage statements. And we want to make sure that some of the minimum of what to do. So most organizations are screening patients for depression. So one of the things that we like to do is to talk to people about how to use that depression screening, particularly the PHQ-9 to kick off conversations around suicide.
And also to remind people that social determinants play a huge role. Housing, economics, relationship problems. Oftentimes, we hear providers might say, listen, I had a patient, we were concerned about him. My team was concerned. I was concerned. He had lots of health problems. He was in danger of losing his job. They had some financial problems. He died by suicide, and I didn't think to ask about suicide because I was so focused on what was going on with him medically that I wasn't paying attention to the role that some of the social determinants were playing.
Alcohol and substance abuse transitions anybody coming out of a hospital, substance abuse, incarceration, foster care are all transitions and put someone at risk.
So when we think about patients at risk for suicide, one of the things that I like to talk to organizations about is whether or not they're adding the code to the problem list. It is so important to know how many patients you have in your population that are at risk for suicide. I love to ask primary care organizations about their diabetic population, and I hear lots about how many people they have with diabetes and how many are controls and what they're doing and their registry. But when you ask about patients at risk for suicide, most organizations can't tell you.
A real easy way is to add the codes to the problem list. Oftentimes, I will hear, well, I'm not sure my patients will want the code added to the problem list. And one of the things I say is, let them know. So listen, you came in today and you talked to me about suicide. And I want to let you know that I'm going to add it to your chart because you're really important to me, and I want to make sure that every time I see you or my team sees you or I talk to or my team talks to you, we make sure you're safe. And I've never had anyone say ... at that.
The other thing is to really think about whether or not you are identifying people who are both at risk and you are then also thinking about patients who are coming back for care. So in other words, when you think about, we often have patients who come in, we think lots about what to do when we newly diagnose them, but we don't think about when they come back for care.
So we had a patient come back in a school-based health center. He came in, was asked about suicide, answered, yes, to a screening question, lots of commotion. Came back three weeks later, saw a different provider to get the same form filled out. Came in and out, and no one asked him about suicide. No one asked him if he was safe because it wasn't written in the problem list, the provider didn't see it in the chart notes, and there was no way to flag him.
So a lot of times, organizations are using the PHQ-9. It's really helpful to think about the PHQ-9 as a jumping point. And so oftentimes, I will say, so I see that you're having trouble sleeping, falling asleep or staying asleep, and that's nearly every day. Or that you're having little energy, and that's a problem for you more than half a days. So I definitely want to talk to you about your trouble sleeping, I can see how problematic that is for you. I also see that you have thoughts you would be better off dead or hurting yourself in some way, and that's more than half of the days. So thank you for telling me you're thinking about suicide.
And then you can launch into your storage statements. So it's really helpful to just go right through.
So the ASQ is a really helpful tool. It is one of the evidence-based tools to really screen people for suicide. I like the ASQ because it has a really nice tool kit on the NIMH website with handouts that you can give to parents, but also to your nursing team. So one of the things we want to talk about is an appropriate level of care, because not everybody that comes in needs to go to the emergency room. So it's often helpful to use tools that will help you assess risk. And assessing risk happens in primary care every day. And there's a couple of ways that you're able to do this that you can work into your existing workflows.
I particularly will often recommend the Columbia scale. The short version. We affectionately call it the primary care version. And what's nice about the Columbia scale is that you can put workflows in place for the yellow, orange and red. So that you can have yellow people will get some safety planning or some questions, you can have something for the orange, and then red is somebody who may need another level of care or somebody with some special training to be able to speak with them. So most organizations will use these colors to help guide the workflows. When we think about suicidal thoughts, we want to know the method and we want to know someone's intent or plan. What the Columbia scale really does is help us know somebody's intent, because that's going to really determine someone's risk.
So we want to make sure about protective factors. The more protective factors people have, the less likely they are to die by suicide. So it's really important to know what people's risk factors are and what their protective factors are. So what are some of the reasons you might not die by suicide today? Safety planning is actually an evidence-based intervention that can happen in primary care. And when we think about safety planning, the minimum for patients who are yellow and orange as an example is that you want to give them the lifeline. We know that the lifeline saves lives. I like to have them pull out their phone and actually put the lifeline in their phone. Actually, have them text it, maybe even call before they leave. We want to give them a caring message.
The Now Matters Now website is a really nice place. I often will pull it up on an office computer or have them pull it up on their phone. So for many patients, these are two evidence-based interventions that will really be helpful for them. The Now Matters Now website. If you haven't visited, it has a nice section for clinicians and for patients.
Emergency safety plan is something that you can give individuals. Often when we were young, we all learned to stop, drop and roll when we caught on physical fire, even though the likelihood that we were going to catch on physical fire is pretty low. So we want to teach people what to do if they catch on emotional fire. And very similar, stop, drop and roll, splash cold water. Oftentimes, primary care practices will give people an emergency safety plan because we know that risk can change.
It's really helpful to remember some guidelines. For example, I like to give a little advice and say, it has to be something that someone can do 24 hours a day and all days of the year. So for those of you who live in New York or Montana or places where it gets cold, 2:00 o'clock in the morning in January is probably not the time to take a walk. So what can someone do instead? Maybe the Now Matters Now website as an example.
And be really creative. Walmart's in a lot of safety plans because it's open 24 hours a day, and it's accessible by public transportation. So we want to make sure, how can we keep you safe today? People have thought about how they want to stay alive.
So certainly, lethal means restriction, making sure that people don't have access to the things that can hurt them. Oftentimes, we think that it's medications we prescribe. And so we should ask questions. So you've talked to me about dying by suicide and using medication, where would you get the medication or where might you have access to that gun? That it's temporary. This doesn't mean that you can't drive again or that you can ever own a gun or go hunting in the fall.
And making sure to address it now. Individual pill packs. I love the Amazon pill packs because they come individually. It's really helpful for patients that are at risk for suicide. And the time to talk to your pharmacy is now, not when you have someone at risk.
So caring contacts are ways that you can reach out and let people know that you're thinking about them. They're not connected with missed appointments but oftentimes, primary care practices will just write people a note on the day that they have identified them as being at risk.
So I want to stop there because we've talked about a lot of different things that primary care practices can do, and I want to be able to give Allison and Dr. Miller a chance to talk a little bit about what their experience has been. So I'm going to turn it over to Allison to tell us a little bit about Sun River Health. And then I'd like to ask you a question actually, about a recent experience that your organization had.
Dubois: Thank you so much, Virna. So happy to join you this afternoon. Sun River Health is a network of federally qualified health centers serving the Southern part of New York. We currently operate about 43 health center locations and care for about 225,000 patients throughout that system of care.
We're offering comprehensive primary care, behavioral health and oral health services in that service area. And so we have a 45-year history in primary care and have been really pleased to have partnered with you over the years as we're working to raise awareness and enhance our practice around suicide, safer care and primary care.
Little: So I know as we were preparing for this, one of the things you shared, which you had said was OK to share is that unfortunately, your organization lost someone to suicide on your team. And so one of the things we're hearing is that organizations are really needing to not only think about their patients but their team members who are often also patients. And maybe just talk a little bit how that changed or re-inspired your organization to think about suicide differently.
Dubois: Sure. It was a few years ago now, but we had an enormously talented nurse practitioner who was working with our HIV and Hep C populations. And she died by suicide while she was still an active member of our organization, and it was a hugely impactful event. And it really emphasized for us as an organization, just as you said, how important it is to be thinking about how we're caring for our team members as well as we are thinking and focusing on care for our patients.
It pushed us to think about the resources that are available to our team members and the way that we talk about suicide. I think that the language was such an important part, particularly right after this had happened, because it was so raw for us as an organization that the language and how we were speaking to each other, how we were speaking to the team members who were closest to our colleague really sensitized us to a lot of the impact of that language and how important it was to be plain spoken about what had happened and also what it meant for people, and what was happening for them in their lives as well.
And it prompted us to really think about the resources we had available in our human resources department and how were we orienting folks to what was available to them.
Historically, we had drawn these very tight lines around caring for colleagues from a behavioral health perspective, that that creates a lot of boundary issues and concerns. But we didn't augment these other resources and really talk about how we were, as an organization, supporting our clinicians and our team members and ensuring that they had access to services. And that we as an organization were comfortable talking about suicide within the practice with our patients.
Really, I think the point you made around throughout the organization, our patients and our team members are talking to all members of the team, not just those who happen to have a clinician. So they were talking to our front desk, they were talking to our navigators. We have members of our facilities department. We wanted to really think about how to raise the consciousness and thoughtfulness of suicide throughout the organization.
Little: I know when you and I had also spoke, you were really working on addressing suicide across your organization and rethinking about your care pathways for patients. And then this little thing called COVID hit, which I can't even imagine what that did to your sort of work life over the past year and some odd. But I know that you've been sort of rethinking now, and we've talked a little bit about how you really need to bake it into your system that training doesn't work unless you put it in your EMR.
And so maybe talk about what you're thinking now in terms of really trying to instill and bake this into your system.
Dubois: Sure. I'd love to start and then I'll ask Dan to join in as well. I think that your point is well taken. When we were organizing ourselves to make sure that everyone had attended training and had an opportunity to think about continuing education credits, but until folks are able to see how those concepts are made easy, how we improve the ease of the pathway in terms of our workflows and the way that the EMR is structured, it's so much harder to maintain the intentionality of being able to do that.
And so one of the things that we have struggled with is how to modify those workflows that we had been focused on in a COVID period and in a remote setting. We really struggled with translating PHQ-9s into a remote setting with our remote techs. And how did all of that work? So it was a lot of work to rethink that.
And it was bumpy. We're still not fully back. Because I think as you have workflows and as you have expectations and onboarding for support staff and how we work with them about the language of, you're not really suicidal. That there's a lot of effort about how we ask questions and that how the tools are effective for self-administration versus through interview. We had a lot of staff turnover in COVID. And so how to rebuild those skills and maintain those skills in that and with that reality has been a lot of effort that we have continued to work on through this period.
Little: I'm wondering, Dr. Miller, with from over the last couple of years, and I know you've talked about seeing suicide in your practice and your patients, how you've changed your thoughts around suicide and what you're doing differently now in your daily practice than you might have done even a few years ago around suicide.
Dr. Miller: Interesting question, Virna. Well, I think this is all, for any of us in practice, practice evolves and practice grows and changes as we grow and change. As Ali is describing, there's the systems level of this, of how we create the systems to make this easier for clinicians and for all of us on our teams.
And I keep coming back to some things you said early on, Virna. And I was writing myself some notes. You used the word hope. You made the statement that not everybody who dies by suicide is depressed. I often think of this in different ways and sometimes, about the differences between depression and despair.
I think most people, in my experience, who are struggling with this in their lives are generally at a time when they're feeling enormously isolated. People talk about feeling alone, in a dark place. And ultimately, and I think you said it, there's the systems, there's the technology. But ultimately, there's a fundamental need for human connection here in how we connect with people, how we express that connection, and how we do it with our patients.
And also I think, Ali as you're describing, what we do organizationally, there's the human connection in large organizations of clinicians who aren't used to this. When we do trainings and we do teachings, they help. But they need to be reinforced by workflow, and I think they need to be reinforced by connection. They need to be reinforced by saying to somebody, if there's a crisis and you don't know what to do, here's three or four people in the organization with their cell numbers. Call us. We're here for you. And whether you actually ever get that call or not, having that number makes an enormous difference to the people on our teams.
Little: And I think one last question Dr. Miller, I'm wondering now, just to talk maybe to some providers listening who haven't really started to address suicide risk in their patients, how is it now that you're, to ask people about their risk for suicide and your own comfort level? Because I often hear from providers, if I ask, then I have to hear the answer.
And so as you've talked, I'm always reminded why your patients love you so much. But I think there was a transition, maybe even in your own comfort level, to hear the word suicide. Someone say, yeah, I am thinking about suicide.
Dr. Miller: Yeah, it's a great question, Virna. And we grow with it, and I grow with it. And as you say, I think when we're young in practice, we are afraid to use the words that scare us. And I think it's really important for us to recognize that if we're not using the word, our patients recognize that we're not using the word. And what they hear overwhelmingly is wow, this thing is so bad. Even he or she can't say the word. So I must be in real trouble.
So exactly as you're saying, Virna, I think what I've learned over the years is, and you said it, is just to ask. I think when I was younger, I had fears of wow, what if I'm wrong? What if I ask somebody and they're not feeling any of this? Will they be upset? Will they get angry? Or will I suggest to them something they haven't considered already and will I be doing harm?
I think as I've aged and grown, I've come to recognize nobody goes out and hurts themselves, because a caring clinician asks them if they might be in danger. That's just not how this happens. I've never had anybody really get angry at me saying, I care so much about you. I really need to know if you're safe right now. It doesn't happen that way.
And so I think as we try these things, we get more comfortable. And overwhelmingly, people are just relieved to have somebody ask them the question and do it in a caring way. I think the language that you suggested is so on target of just, you're a really important person, and I really need to know that you're safe right now.
I had a patient recently, when I said something like this, tell me, nobody has ever before told me that I was important. I need to take a few minutes with that. There are really basic, just connections on a human level that makes such a difference here. And they're real. So I appreciate the way you framed this for all of us.
Little: Well, thank you. I really appreciate you, Dr. Miller, and you, Allison, I'm so proud to have you as colleagues. Thank you both.
Dubois: Thank you.
Dr. Miller: Thank you.
Little: Thank you.
Unger: You can subscribe to Moving Medicine and other great AMA podcasts anywhere you listen to yours or visit ama-assn.org/podcasts. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.
People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.
The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.