How a Large Health System Is Working to Prevent Suicide

In response to alarming rates of suicide in the United States and in the communities it serves, Atrium Health, one of the largest health care systems in the Southeast, launched a prevention program in 2019 based on the  Zero Suicide Framework. This framework promotes a holistic approach to suicide prevention in health care settings, including suicide risk screening, assessment, and follow-up care interventions.  

Courtesy of Kate Penny

Kate Penny is a licensed clinical mental health counselor and the program coordinator for the Zero Suicide initiative at Atrium Health. Penny helped to implement the initiative across the system’s multiple primary care, behavioral health, and hospital settings and continues to oversee the program’s progress. She recently spoke with Pew about Atrium Health’s suicide prevention practices in emergency departments (EDs) across the health system.

This interview has been edited for length and clarity.

How is suicide prevention implemented in the ED?

The suicide care pathway—which includes screening, risk assessment, and discharge care—guides how we implement prevention practices at Atrium Health.

The first step in preventing suicide is identifying whether a patient is having suicidal thoughts or planning an attempt. So we screen all ED patients for suicide risk, regardless of the reason for their visit. Typically, a registered nurse asks the patient a series of simple, plain-language questions as part of a validated screening tool.  

We want screening to become as routine as asking patients about allergies, so the tools are easily accessible through the hospital’s electronic health record system. This initial suicide risk screening usually takes less than a minute, and, on average, about 98% of patients screen negative.

What happens if the patient screens positive for suicide risk?

If the patient answers yes to any of the screening questions, the nurse connects them with the ED’s psychiatry team for further assessment. That team usually consists of trained clinicians including licensed social workers, therapists, and physicians who will ask additional questions and administer appropriate interventions based on the severity and immediacy of a patient’s risk. This assessment can take about 20 minutes.

About 1% of patients are found to be at immediate risk of harming themselves and may require inpatient care before discharge.

And what does discharge care look like?

Evidence-based discharge care happens before the patient leaves the hospital, including safety planning and lethal means counseling, which can take up to 45 minutes. These discharge care services provide patients with resources and strategies for their ongoing safety and well-being and can be a great opportunity for the provider to develop a rapport with the patient so that any follow-up contact with them is more effective. We also give our patients a “warm handoff,” which means the discharge care clinician makes a personal introduction between the patient and the outpatient mental health care provider.

What effect have you seen from these follow-up contacts?

Atrium Health’s leaders have noticed a reduction in suicide attempts and ED return visits when our staff follows up with people after discharge. Follow-up contact consists of a telephone call from staff within 24 to 48 hours after discharge to check on a patient’s well-being, offer support, and help address barriers to outpatient care. We also send cards to their homes with inspirational and supportive messages. Because of the connections we’ve built, those patients know that they have someone to reach out to directly if they have questions or concerns about their condition or hospital stay.  

What are the challenges in effectively implementing the suicide care pathway?

Challenges include adequate staffing to conduct all these services, as well as time for providers to complete all the training they need to offer them. It can also be difficult to find available outpatient mental health care providers in a timely manner.

How is Atrium Health navigating these challenges?

Suicide care training is a priority for us—staff show more confidence in conducting risk screenings and safety planning when they have adequate training to do so. That’s why we provide ongoing training in evidence-based interventions like Counseling on Access to Lethal Means and motivational interviewing techniques for risk assessment to ensure that our patients receive the best care backed by the latest evidence.

And if we cannot find an outpatient mental health care provider during a patient’s discharge process, we follow a transitional “pathway” program where clinicians check in on patients within 24 hours of discharge, then daily, if needed, and gradually taper the calls off once they start receiving outpatient care. This process of “wrapping our arms around” our patients continues for 45 to 60 days post-discharge.

What do you want to tell other clinicians who are interested in implementing the suicide care pathway in their health system?

It’s key that you have clinical and executive leadership’s support in this endeavor. And implementing the interventions can be a learning experience, from figuring out what processes work well in what type of setting, such as EDs versus inpatient care, to ensuring that there are enough trained providers available to work with patients on each step of the pathway.

When we began using the Zero Suicide framework, we were overwhelmed and didn’t know where to start. We first took small steps, then made changes and improved processes as we went along. Having patience and listening to feedback from teammates, patients, and patients’ families was imperative.

Is there anything else people should know about your suicide prevention programming?

Both patients and their families have given positive feedback about the care they receive in our settings. Previously, family members were sometimes excluded from their loved ones’ mental health care due to HIPAA concerns, but our suicide care pathway ensures their involvement in the process and helps them feel like a part of the recovery journey.

We also get positive feedback from patients after follow-up contact from our team, which lets them know we are thinking of them and that we care. We have heard patients say they put the cards we send on their mirror or refrigerator so they can see them daily and feel hopeful about their recovery. These are all important confirmations that these interventions make a real difference.