Training Opportunities

NJH Suicide Awareness Response Training

National Jewish Health offers a two hour in person training twice a month recommended for all staff. In this class, we cover the role of all staff to complete initial assessments on patients who express concern for suicide. You can sign up for one of these classes on NetLearning. Once logged in to NetLearning select Learning Opportunities (Enroll) and search for “Suicide Awareness Training”.

Columbia-Suicide Severity Rating Scale Screen Version

Using the Columbia-Suicide Severity Rating Scale Screen Version is required when evaluating an inpatient and recommended when working with outpatients. This free 30-minute training offered by The Columbia Lighthouse Project is recommended to learn about the screening tool.

Training:

https://practiceinnovations.org/Resources/SCORM/CSSRS

Overview website:

https://cssrs.columbia.edu/

NJH Columbia-Suicide Severity Rating Scale Screen Version and Brown Stanley Safety Plan Training

We offer the ability for in person training on the use of the Columbia Suicide Severity Rating Scale Screen Version while completing a suicide evaluation. The presentation also covers completing a Brown Stanley Safety Plan and Colorado M1 Holds.

Download Columbia Suicide Severity Rating Scale

NJH Suicide Awareness Quarterly Virtual Learning Collaborative

Look out for emails with links to upcoming quarterly trainings.

Upcoming 2022 Presentations:

2023 Presentations to be Announced Soon!

Previous Presentations Video Recordings

January 27, 2023

Suicide Assessment and Intervention Policy Net Learning

Thank you, everybody, for joining. My name is Elizabeth Langhoff. I'm the licensed clinical

social worker here for the adult clinics at National Jewish. Today, during our learning

collaborative, we're going to be talking about the suicide assessment and intervention policy.

This is a presentation of the net learning that you'll be seeing this year in 2023, that

all staff at National Jewish will be asked to complete. You will see that this is being

recorded. Part of the reason of why it's being recorded is during that learning, people will

have the opportunity to link to this video to watch this class, rather than read the

slideshow individually. The objective of this net learning and also the learning collaborative

today is so that people are familiar with the National Jewish suicide assessment and

intervention policy. Suicide awareness is important, especially in hospital settings.

And working in healthcare, working in a healthcare setting means you may come in contact with

patients who might be suicidal. And that's everybody might come in contact with somebody

be suicidal. And all staff, regardless of role, need to be aware of the policy and the procedures

for working with an individual who may be suicidal. On top of that, hospitals also have

a legal responsibility to provide the appropriate care for people who are at risk for suicide.

Now, some might be joining us or watching later down the road and wondering, well, if

I'm not a clinical provider, why and or how could I become involved in the care of a patient

who might be suicidal? The reason why is because you can always come across somebody who is

in need. If you're walking through any of the campus where patients have access to,

so for example, cafeteria, the bathrooms, the main entrance or the waiting room, you

could come across a patient or somebody in general who just seems like they need help.

And it's part of our job to help that individual. Also, on top of just being in an area where

somebody might be, many non-clinical roles still come in contact with patients on a daily

basis. And we provided some examples. They can include security, scheduling, billing,

financial services, food services, environmental services, and librarians work with patients

on a daily basis as well. We also want to acknowledge and recognize that people don't

look at somebody's badge to determine if the person in front of them is the appropriate

person to help them. They just see a badge and say that's somebody I can get help from.

The goal of today is to go over the entire policy, but there are very key points that we can point

out at first. And these are also the key points that help for the non-clinical staff

of what to get out of our policy. The first one is to acknowledge and recognize that all staff

are responsible for identifying a patient at risk for suicide and notifying the appropriate

provider for further assistance. People who have been identified or patients who have been

identified to be at risk for suicide must be supervised at all times until that suicide risk

evaluation is conducted. If we've identified somebody is at risk for suicide, it is then the

responsibility of a licensed clinical social worker, a psychologist, or physician to do further

evaluations. This policy also goes over the policy for if somebody needs to go to the restroom

who's been identified at risk for suicide. The policy states that somebody must be supervised

by a same-sex staff member to a multi-stalled restroom or the patient can use the private

ligature-free restrooms which can be found on the pediatric behavioral health unit A207A

or in the center for outpatient health fifth floor T536. If you work on one of our off-site

locations, it is to go to a multi-stalled restroom. If you do not have a multi-stalled restroom,

the person would still need to accompany the person to a bathroom as well.

Like all policies at National Jewish Health, our policy does start with a principle and purpose.

The main part of our principle and purpose that is important for people to know and acknowledge

is that National Jewish Health is not a designated facility approved by the state of Colorado for

the treatment of psychiatric patients who are in at an immediate risk to harm their self or others.

So the main goal of our policy is once we've identified somebody who is at an immediate risk,

we transfer them to a higher level of care. This policy also has a definition section and the first

definition is the suicide risk assessment definition. And this is an assessment that

can be done by all staff at National Jewish Health. The main goal of this assessment is to identify

that there is a need for further evaluation by this patient. So that involves asking the patient,

are you having thoughts of suicide, or are you thinking about killing yourself,

and then also asking them, do you have a plan? There is additional training on how to complete

an assessment and it's offered in the suicide awareness and response training. More information

about that can be found under the education tab on the suicide awareness spider web page.

So please go to that page for further information about how to do this assessment.

The next definition that's important to recognize in this policy is called a suicide risk

evaluation. The suicide risk evaluation comes into play after a positive assessment has been done.

So these are done by our licensed medical staff here and that includes both licensed mental health

providers, which are our licensed clinical social workers and psychologists, and our licensed

medical prescribing providers, which are physicians and psychiatrists. You do not see nurse practitioners

or physician's assistants on this list because in the state of Colorado,

unless you are a psychiatric nurse practitioner, you cannot put somebody on an M1 hold. So we have

made the decision that these further evaluations need to be done and completed by the individuals

who could put somebody on a hold if it's needed. The key part of an evaluation is that you must

complete a Columbia suicide severity rating scale screen version with that patient.

This on the screen is a Columbia suicide

severity rating scale, but what it is is a workflow of going through the six questions

of that scale and what must happen depending on the answers of the six questions.

We'll go over it a little bit later in this class as well today, but this is for the licensed

clinical social workers and psychologists and physicians to be aware that this is in the policy.

Again, we do offer additional training on how to complete an evaluation and that is done in the

National Jewish Health Columbia suicide severity rating scale screen version and Brown Stanley

safety plan training. Again, if that is something that you want training on, please go to the

education tab on the suicide awareness spider web page and we will offer you that training.

The policy is separated in different areas depending on what type of patient we are working

with. So the first part of the policy are what do we do for inpatients who come through our

doors as an inpatient. Upon admission, all inpatients 12 years and older are assessed

for suicide using the ask suicide screening question or ASQ screening tool. This is actually

found in the medical record under the nursing assessment. We will also have the same tool in

EPIC when EPIC comes. In all instances, a patient who presents with express suicide risk or suicide

self-injuries must be supervised at all times once we have been made aware that there is a concern.

Staff needs to be aware of the surroundings and to remove any lethal objects in the immediate

reach of the patient. Once that positive screen occurs, it requires a suicide risk evaluation

to be completed immediately. So any staff member who has identified a risk will need to notify

the licensed medical prescribing provider or the licensed mental health provider to complete that

suicide risk evaluation. There are two outcomes that can come from an evaluation for our

inpatients. The first is that the patient will be determined to be at an immediate risk for suicide

and therefore they will need to be transferred to a higher level of care or an ER. This transfer

can happen either voluntarily or the patient might have to be placed on what's called an M1 hold.

There is also the possibility that the evaluation will have the patient screen not to be at an

immediate risk and our policy requires that three things must happen if a patient is determined to

not be at risk. The first is that they must be provided the national suicide prevention line,

which number is 988, and the option to receive mental health provider referrals.

When determined appropriate by that suicide patient evaluation workflow, that provider must

also complete a safety plan with the patient. Again, there's more information offered in that

additional training that we will not be covering today. So if you need that additional training,

please reach out to us so that we can provide that to you. The next part of the policy is our

outpatient and this is for the main campus during regular operating hours, which is Monday through

Friday, 8 to 5, except holidays. For this, we do not screen patients when they walk through the door,

but all patients who express suicidal thoughts or show active self-injurious behavior will have that

suicide risk assessment done, which was asking those questions about are you having thoughts

of suicide and do you have a plan. In all instances where the answers are positive,

the patient must be supervised at all times and again will be removing any objects around that

patient that could be an immediate risk for them. Then that positive screen does require a further

suicide risk evaluation to be completed. Staff will immediately notify the licensed medical

prescribing provider or the licensed mental health provider to complete that suicide risk

evaluation using the Columbia. In our outpatient setting, the outcomes for an evaluation are the

same as our inpatient setting, where the patient might be determined to be at an immediate risk

and therefore will need to be transferred to a higher level care. Or if they are not an

immediate risk, they can stay at National Jewish Health and continue to see their appointments,

but we still need to provide them that national suicide prevention lifeline,

the option to receive mental health provider referrals, and when determined appropriate,

to complete a safety plan with the patient. The next section of the policy is our off-site

outpatient locations and this also includes our main campus outside of regular operating hours.

Again, all patients who express suicidal thoughts or show active self-injurious behavior will have

that suicide risk assessment completed. They also will need to be supervised at all times if it's a

positive risk that comes. That positive screen still does require a suicide risk evaluation

to be completed immediately and staff will immediately notify the licensed medical

prescribing provider or the licensed mental health provider to complete that suicide risk evaluation.

The next step is the part where it changes compared to the main campus during regular

office hours. In cases where there's a positive suicide risk assessment and a licensed medical

prescriber is not available to complete the suicide risk evaluation, staff will call 911

and request a police officer to respond to evaluate the patient's risk. The reason why

you need a police officer is because paramedics are not able to place people on M1 holds,

so if that patient is not willing to go voluntarily, they can't take the patient,

so that's why we request the police officer to come and do essentially a wellness check.

The off-site outpatient incomes of an evaluation are the same. They could mean that the patient's

determined to be at an immediate risk and they do no longer meet the level of care we provide on

our off-site locations or outside of our regular business hours and therefore they need to be

transferred via that M1 hold or voluntarily, but patients could also be determined to not be an

immediate risk. Again, they will continue to see their care throughout that appointment that day,

but they need to be provided the national suicide prevention hotline, the option to receive mental

health provider referrals, and when determined appropriate, we need to complete a safety plan

with that patient. The policy does also cover our health initiatives line. When participants

indicate any comments that they might be suicidal, we have to talk to them about that and we need to

do the suicide risk assessment. During call center hours, if a participant reports suicidal ideations

and a plan and or means, the coach will alert the health and wellness supervisor.

Outside of call center hours, if a participant reports suicidal ideation and a plan or means,

the coach will also contact the on-call supervisor. It is the supervisor's job to provide

assistance to the coach and contact emergency services local to the caller to arrange a wellness

check. This wellness check should be done at the address listed on file or at the participants

reported current location if they tell you that they are somewhere else.

The coach will attempt to keep the participant on the phone as long as possible and that includes

up until the point that you hear the wellness check being conducted by the police department

in the background. If the participant ends the call or the call is disconnected for any reason,

the coach will attempt to contact the participant again and alert the supervisor that the call

ended so that that information can be provided to the police department during that wellness check.

The coach and the supervisor will document actions in the quit pro system.

On all other campuses, the telephone encounter section of the policy is there as well.

All patients who express suicidal thoughts or active self-injurious behaviors while we're on

the phone with them will also receive that suicide risk assessment. If that assessment is

positive, the staff member will still notify a licensed medical prescribing provider or licensed

medical prescribing provider or licensed mental health provider to conduct a suicide risk

evaluation and or request a wellness check if that call is not able to be transferred to that person.

The goal is to attempt to keep the patient on the phone as long as possible while attempting to

immediately transfer the call. But please note, do not transfer a call if there is not somebody on

the other line to accept that transfer. So you need to have already contacted that individual

and tell them this call is coming to you. If you're working with a pediatric patient or a parent

of a pediatric patient, the phone call will be transferred to the pediatric care unit

at 1239 for pediatric patients. If you're working with an adult patient, the adult licensed clinical

social workers during business hours will be contacted or the adult nursing supervisor.

If the patient or caller hangs up or the call is disconnected,

please include that information to the pediatric triage team or licensed clinical social worker.

The outcomes of a evaluation done over the telephone could include if somebody is at

an immediate risk or they have disconnected and our attempts to call them back have failed

is for a wellness check to be called to the local police department at the address on file

or last known location of the patient. Patients who are determined not to be at immediate risk

for suicide after the suicide risk evaluation is completed will still be offered the national

suicide prevention hotline, the option to receive a list of mental health providers,

and when determined appropriate, a safety plan. Safety plans can still be done over

the phone with a patient and they don't have to be done only in person.

The last section of our policy covers what happens when we receive messages and these messages can

include receiving a voicemail, a questionnaire, or a porter message suggesting a suicidal ideation

plan or attempt. Our policy states that we will attempt to reach the patient by phone

immediately after receiving that voice message question or questionnaire.

If we are unable to reach that patient, we will call a wellness check which again will be called

to the local police department at the address on file or the last known location of a patient.

If we are able to reach a patient, we will do that same evaluation that is done over the phone

and you'll go back to the previous section, the telephone encounter section of the policy.

In conclusion, we want to remember that all staff are responsible for identifying a patient at risk

for suicide and notifying the appropriate provider for further evaluation. Staff can receive

additional training on how to do this and the suicide awareness and response training

which is something that you can sign up for on that learning under the other learning opportunities

you type in suicide awareness and the classes will pop up. Any patient who's been identified

to be at risk for suicide must be supervised at all times until that suicide risk evaluation

has been conducted and completed. Licensed clinical social workers, psychologists, physicians,

and psychiatrists are responsible for completing further evaluations. Any patient needing to use

the restroom must be supervised by a same-sex staff member to a multi-stall restroom or the

patient can use the ligature-free restroom found on the Pediatric Behavioral Health Unit A207A

and the Center for Outpatient Health which is on the fifth floor T536. Please always remember

that there is additional educational opportunities and information that can be found on the suicide

awareness spider web page. If you go to spider web on the left side, there's a long list of things

in alphabetical order. Scroll down to the bottom and click on suicide awareness and you'll find

multiple different information. That ends the presentation for today but I am going to take

questions. I do already see that there is a question in the chat with if the patient becomes

belligerent while on while here on site. So that is covered in the workplace violence policy but

if you are with a patient and the patient starts becoming aggressive towards you or making threats

or pulls out a weapon, you will leave that area and clear the area and call 911.

Does anybody have any other questions?

All right, well I thank you all very much for joining us. You will be seeing this in

that learning this year. Please reach out to the suicide awareness council if you have any further

questions.

October 6, 2022

Ensuring a Safe Environment for People who are Suicidal

Good afternoon, everybody. My name is Elizabeth. I'm the licensed clinical social worker for

the adult clinic here at National Jewish Health and the chair of our Suicide Awareness Council.

I appreciate you joining us today for the virtual learning collaborative. Today our

topic is to talk about ensuring a safe environment for people who are suicidal. So this topic

not only covers for people who are suicidal while they're here at National Jewish Health,

but I think it's important to recognize that whenever we do these learning collaboratives,

we're not just talking about our patients because we acknowledge and recognize that

suicide doesn't just happen in medical facilities. It's not just something that we could come

across here. So outside of here too, you might come across and these are tips and things

to help you to think of. You'll see NJH mentioned a lot too, but it can help you with that outside

as well too. So we're glad to have you. There's going to be some times today that I might

ask you to include yourself in the chat if you want to help with the discussion in the

chat as well. And so, and feel free to put any questions there. I'll try to get to them

throughout the presentation as possible. So today I wanted to start with why it's important

for us to even be having a conversation or thinking about environmental risk factors

for suicide. And especially in a healthcare facility, we do have additional expectations

from the Joint Commission to have environments that are safe for people who may be suicidal.

So the first reason, and it's always important reason for me is because when we're talking

about suicide, we are talking about saving a life. So the first thing to remember is

that when it comes to the environment around us, the reason why we want to think about

this and we want to be proactive about it, or when something has happened, be aware

that somebody needs help and there's these environmental factors, is to save a life.

We want to save lives and the way that we do that is to be aware of what is around us.

The second thing that we want to talk about the reason of why this is important, especially

in a healthcare facility, is because it's a liability issue. So Wilson Medical Center

in North Carolina is actually possibly going to lose their Medicare contract after state

regulators identified three instances that directly impacted patient care and safety.

Some of these involve deaths, not all three of them did, but one of those out of the three

that they're being investigated for was directly linked to a suicidal patient. And so the incident

involved a patient who was suicidal. He had been made aware that this individual was suicidal,

locked himself into a bathroom in the hospital's emergency room lobby, and then threatened to

overdose on medication. And so the regulators decided that the hospital should have confiscated

those medications from the individual, which is part of that environment of taking their personal

belongings from them. Also, the fact that a patient was able to lock themselves in a bathroom is

seen as a risk factor when it comes to Medicare too. So there are multiple steps that we can do

to keep an environment safe and to ensure a safe environment for patients who are suicidal. And

these are the things that we're going to go over today. So the first one is to identify a need

for a safe environment. Not all people who are suicidal are just going to blatantly tell us,

I'm suicidal, or I'm having thoughts of suicide. Some definitely do, but not all. So screening for

suicide risk. When, if you think that there's a concern with a patient, there may be expressing

a lot of signs of depression and sadness, you definitely want to screen them for suicide.

Never be afraid to talk about suicide with a patient and to be open and blunt with them about

it. Research actually shows that when somebody is open and honest and talks to somebody and

directly ask them about suicide, you are more likely to save their life than the opposite of

some people have fears that you're maybe putting that idea in their mind. So first we have to

identify that there's a risk. Then there's also proactive and reactive things that we can do in

our environment around us. So proactive is what are things that we can remove from the room before

we even know that there might be a patient who is suicidal? And then the reactive actions are,

we've just identified somebody who is suicidal, so what do we do at that point when we just

identified that they're suicidal? And that's when we remove immediate risk during a crisis. So if

we have a patient who's told us or we've identified that they're a suicide risk, we need to remove

anything within their arm's length or anything in that room that could be an immediate risk

towards them. And we're going to go through the very long list of different things in a room that

might be dangerous for somebody. We also need to be very aware of personal belongings that patients

bring in with them. We don't check personal belongings when people come through National

Jewish Health. We don't have metal detectors at our doors. So this is something that probably is

one of the most dangerous things in that room. We're going to do an activity too, or I'm going

to have you think about what is in your personal belongings. The next thing that we need to do is

when we risk can't be removed, we have to implement policies and practices. And this is the most common

practice that occurs in hospitals, because you want a hospital environment to be a welcoming

environment. And when we really start talking about the risk factors and the different things that are

look at your risk. If you remove all of those, you have a very empty, plain room. And most people

probably wouldn't want to go to their doctor's office and have it look like a jail cell.

So this is the most common practice. And it's definitely the practice that we do here at National

Jewish. Slide wasn't moving forward. So what we do at National Jewish Health is a little bit of all

of these. Our policy was developed and implemented, keeping this in mind that we have to stay with

patients while we're here at National Jewish, because we have risk factors in our environment.

We also do ligature reviews or environmental risk for suicide assessments. And these actually do

result in physical changes that are made into the environment. And then also education, which is why

you are all here today. So I appreciate you joining us today to learn about the risks that

are around us for a person who might be suicidal. If you only learn one thing today, I have Yoda here

on the screen to help you remember the one thing that you learned. It is to remember that National

Jewish Health is not a ligature free establishment. So what that means is that we have environmental

risk for patients who have been identified at risk for suicide. There's only two rooms in this

building. And we'll talk about those two rooms where considered ligature free, but the rest of

National Jewish Health is completely not ligature free. And so we medicate our environmental risk

by the presence of a one to one whose job is to constantly observe and escort a patient to

ensure their patient's safety. This is part of our policy. And it's the first thing you can see.

This is actually our suicide assessment and intervention policy. You can see from the slide

that the policy is actually seven pages long. So it goes into a lot more detail. But one of the

important things to look throughout this entire policy, all those arrows are pointing at different

sections in this policy where it says that this patient cannot be left alone at any point in time.

Our policy even covers how does a patient go to the restroom who's been identified for risk for

suicide. The principle and purpose is the very first part of all of our policies. And you can

see in that second sentence on that, it says that this person will be supervised at all times until

the suicide risk evaluation is completed. So when we have a policy that repetitively talks about the

fact that a patient will not be left alone, if a patient's ever left alone and something were to

happen, there are multiple places in this policy where we can get in trouble for leaving that

patient alone. So again, to my point that if you only remember one thing today from today's

presentation is to remember that patients who identify at risk for suicide can never be left alone.

The next part we do are environmental risk for suicide assessments. And these are our ligature

risk assessments. Peter is the leader of doing these, Peter, from safety. And we do these on a

yearly basis. And this is one of the proactive measures that we do to keep national Jewish safe.

It's important to also recognize that all staff at National Jewish Health can look for and report

concerns. So when we start going through this presentation, and I start talking about what are

the risks that we have, if you see something, you need to let us know. And I'm going to tell you

where to also let us know that you see a risk that you think might be concerning. So this is

actually a Joint Commission thing that we do. So we go through and you can see on the right side

of the screen, it's very small, because I don't expect you to be reading that part. But what it

is, is it's a list of all the risk that the Joint Commission feels could be mitigated during a

ligature risk assessment. We also, when we walk into the room, we randomly choose rooms throughout

National Jewish. And we basically walk in with this concept in our mind to think, if I am suicidal,

what could I use in this room to either hurt or kill myself? So we go into that room thinking that

way and trying to remove the risk factors that we can. Now, there are some risk factors that

we're not going to be able to remove. And National Jewish as a whole is not meant to be an

establishment that provides long term care for people who are suicidal. So they have different

requirements than we do. So we have to acknowledge and recognize what are things that we can change?

What are things that aren't cost effective or really wouldn't help benefit other patients if

we were to remove them? And then from there, what changes do we make going forward? Remembering,

again, that number one policy is that we do not leave patients who are suicidal alone.

So on the screen, you can see six different pictures. These are actually pictures from the

most recent ligature review that was done within the last couple of months. And the arrows are

actually pointing at things that are considered a ligature risk. So in that first picture on the

left, you see that we're actually looking at the different types of cords that are being used in

drapes. Now, we did find out that the cords that are used in the Center of Outpatient Health

are ones that are designed that if anybody puts any weight on them, they're going to fall off.

So they're not used, but it's still a cord. And it's something that we need to be aware of.

The middle picture on the top row is from the adult inpatient area. And we have a couple risks

that I've pointed out in this picture specifically that there's the devices that are holding up the

television and actually cork boards are considered a risk for people who are suicidal, mainly because

of those push pins. So this is actually an example of one of the things from the ligature review

that is going to be removed. So you can see something came across, we decided proactively,

we should remove that risk. The third picture on the top row is in the pediatric behavioral health

department. These are the offices that they have. And you can see that there are coat hooks on the

back of that door. And there's also the ability to lock the door from inside the room. So these

are both things that are being looked at to have removed because again, changes that can be made,

but don't impact everybody. Well, do impact everybody, but are reasonable changes that we

can make. One of the things that is throughout all of national Jewish health is that bottom

left picture and that is a dropped ceiling. So drop ceilings are very common in medical

and a lot of different facilities and drop ceilings are actually considered a ligature

review risk. But this is an example of something that we don't have the ability to change. We

can't go throughout all of national Jewish health and remove every single drop ceiling.

It's not a financially feasible option to do. So just alone, our dropped ceilings are a reason

of why we need a one-on-one with every single patient. The middle picture on the bottom is

actually looking at the cords. So we go all the way down to looking at the desk that you are sitting

at and that a patient or a provider could be sitting at and what are the items that are on

that desk that could be a danger to them. Then the last question is looking at the closets.

This is again the inpatient side and looking at the fact that there are coat hangers. There

are more hangers on that door as well too. From this ligature risk review, this is something new

that we will be implementing is we actually have designed and created a form for education for

sitters and staff of ligature risk. So any employee who's going to be somebody who might

sit with a patient who might be suicidal, we're going to go and we're going to educate them.

This particular form this year is based off of from that ligature risk review, what did we find

that was dangerous and what do you as the person who's sitting in that room need to be aware of

what is dangerous. Now let's be a little bit more specific about what is a safety risk in

the environment around us and I put some fun little memes and GIFs on there so that you can see

a little smile in your day today. So the Joint Commission provides the following definition for

ligature resistant. So we're not ligature resistant, but ligature resistance would mean

being without points where a cord, rope, bed sheet, or other fabric material can be looped

or tied to create a sustainable point of attachment that may result in self-harm or loss of death.

So this is a very long list of what are the things that are dangerous around us. So sheets

and blankets, privacy curtains, plastic bags, cords and tubing, and when you think about cords

there are a lot of cords that can exist. Tubing we think of things maybe more of like the oxygen

tubing that your patient has, tubing for a suction tool, things along those lines, but the call light

cords, telephone cords, monitor cables, tubings, when I look around my desk right now I have

multiple cords that are in this area as well. Also objects with sharp edges, so cabinets,

you can sometimes look at a cabinet and see that it's a very sharp angle that somebody could just

intentionally bang their head against. Chairs and other movable furniture, so if there is anything

in that room that can be moved to barricade the door that's considered a risk. The other thing about

chairs is chairs are actually can be used as a hanging point. Somebody can technically hang

themselves from just four inches off of the ground. That's the reason why most prison beds if you've

ever visited a prison are actually directly on the floor is because they're trying to remove

this ligature resistance. Unnecessarily equipment, we think of a lot of equipments and when we get

to pictures I'm going to show you some of that equipment that's just randomly kept in a room

even if a patient isn't using it. Then we also have to look at things that patients can ingest,

so thumb tacks or magnets or medications around them. Mirrors have risk to them, you can break

a mirror and create a sharp edge and a knife that you can then use. Ligature points at any heights,

again I said down the way down to four inches to all the way up to high. Anything that I can wrap

a cord around and get around is a danger at that time. The hand sanitizer dispensers are also

considered a risk factor. TVs and monitors with glass screens, exposed electrical outlets,

so they're having us look all the way down to the outlets of what is dangerous about the outlets

that we have, and patients' belongings. Now there are also times when I think that people

forget we have this room. This room is normally set this way, but maybe sometimes there's additional

things that come into play that could be a risk, and that's the unintended items such as utility or

housekeeping carts that contain hazardous items. So if you think about it, it's the end of the day and

the housekeeper is pushing their cart down the hallway or our maintenance department, they take

their tools with them and they put them on a cart. That's leaving an item that could be dangerous

for somebody who is suicidal. This overall, anything that can be used as a weapon,

and when you think about it, that's a very long laundry list. Audioscopes, they're pretty heavy.

That's an item that could be used as a weapon. And then anything sharp, so sharp containers,

broken mirrors, broken plastic holders, or even kitchen utensils. Maybe there's been a

meal that was delivered to this patient. We also are aware that handrails can be dangerous. It

provides something that somebody can put a hook around. Doorknobs is something that you can also

put a hook around. You can put door hinges as well. The shower curtains, exposed plumbing and pipes,

soap and paper towel dispensers on the walls, and light fixtures. So as I mentioned, this is a pretty

long list of things that they've identified, and this is the Joint Commission identifying that

these are things that you need to be aware of and these are things that you need to find ways to

mitigate. I also want to talk about what are the risks that can be in personal belongings, and the

way that I want to talk about this is I want you to think in the bag that you carry with you on a

regular basis or the bag that you bring to work. What is in that bag that could be used to hurt or

kill yourself? And I have on here the picture of the luggage as well. We have a lot of out-of-state

patients who will bring their entire luggage with them because maybe this is their last appointment

before going to the airport and they had to check out of their hotel. So we have patients actually

carrying their entire luggage. So think about too, when you go traveling and you pack a bag

to go away, what are the different things inside that personal belongings that you have that could

be a risk? It's one of the most dangerous things because of the fact that we don't check personal

belongings on patients when they come through the door, and as I mentioned, we don't have metal

detectors to make sure that what's inside there is safe. Now I also want you to take a moment

and look around the room that you're tuning in on, and I want you to think about all those

things that we just listed that are considered a safety risk. What do you have in the area that

is around you that is considered a safety risk? Now we're going to take a little bit closer look

at National Jewish Health. All of these pictures that were taken were pictures that were taken at

random in rooms. They were not set up, so we just walked around, we found a room, we took a picture

of that room at that point in time. So this is one of the rooms in the Center for Outpatient Health.

Again, it was randomly chosen. We didn't add anything or remove anything from this room,

and if you have access to the chat button, if you want to provide, let me know anything in this

room that you think might be a risk for a patient who is suicidal. I'll give you a second to jump

on that chat and tell me what you think is dangerous. I like that. Just about everything.

That is completely true that just about everything in this room is a risk.

So I've circled just about everything in the room for you as well too. So there's some key points

that we want to point out in this particular picture that we're looking at. So on the right,

you see that sharps container. They like to say that you can't get into sharps containers.

That's a lie. I could absolutely get into a sharps container without the key that's actually needed

for it. The other thing that I found interesting about this room is the number of chairs that are

in this room. So you have the chair that the provider would be sitting at, and then there's

three additional chairs on top of the exam table. The other thing about exam tables to remember

is that exam tables actually do have drawers in them. Did somebody accidentally put something

in that drawer? Nobody else knew it was there. Same with that cabinet that's above the workstation

there. This is back to the Smith Clinic. Again, we can say absolutely just about everything in

this room is dangerous. And if you see something in particular that you would point out, feel free

to add that into the chat. You do have luggage storage rooms in both the COH and Goodman. So yes,

we do have luggage storage. It'd be great for patients. I've seen some patients who refuse

to take their luggage to the luggage storage area as well too. So one of the things about this room

is in the back corner, you can see that there's a trash can in this. It's hiding behind the exam

table there. That trash can actually has two bags inside of it. Underneath those bags was the entire

row of additional plastic bags. You also see that there are hooks hanging on this door, and there's

a lock to this exam room. So another opportunity for somebody to lock the room. Now this is the

exact same room. So we're really looking at this room from two views, because this is probably

most likely the direction that the patient's going to be facing. And when we circle these ones,

we're circling a lot more. So one of the things that's circled on there, as you can see it,

is the blue magnet that is above the computer screen. Does anybody know what happens when you

swallow a bunch of magnets? Well, I'll let you know. They actually interact with each other

when they get down to your intestines, and they can rip your intestines and cause holes in your

intestines. I don't understand why children's toys have magnets, but even those things of,

well, I have a thing that I could use a magnet on, and when we add magnets to that, those magnets

could be used as a risk factor. Also, those plastic containers that are holding up the

paperwork on top of the work shelf, that can be used. If I break it, I've now created a sharp edge.

We also have the micro kill wipes, and we've now changed to the green bottles.

On those micro kill wipes, it actually specifically says, if you ingest this, you can die from it.

These are things that could possibly not be laying out but be put inside a cabinet that we

don't know is there. And the bag that says Diane on it, that's the personal belongings of the patient.

Now, we're not going to forget about our inpatient side, because we have inpatients

here at National Jewish as well, and this is one of our inpatient rooms that was randomly selected

to take a picture of. And we're going to take a look at the risk factors that are in this room,

as well, too. So again, we're pretty much circling everything in this room. We can see that drop

ceiling above. Actually, the open fire distinguishes are considered a ligature risk.

We can see multiple bags and multiple corners. There's an IV pole in there. The suction machine

actually has some, in the bottom of the part of the suction, there's a white powder in there.

We looked that up during our ligature review and discovered that that white powder was actually a

toxic white powder. So what are we doing? We're working on removing that white powder and getting

a different powder so that it's less toxic if somebody were to digest that powder.

Now, this is also another inpatient room. This is the same inpatient room, just facing the other

direction. So think about all those other red circles we had, and now we're facing this direction.

But there's one thing about this room that I want to point out that you can see is something that's

already been addressed, and that's the drapes that are being used in the room. So these drapes

don't have a cord there. They have a long metal that is used to open and close those windows.

So this is an example of a way, and the inpatient units that we've thought of,

okay, we've got to eliminate this risk. This is a risk that we can do. Now, some of you might be

wondering, why is the clock circle? Well, the clock has a glass front to it. So you've created

a glass front for somebody. Now we're going to move to the intermediate care clinic. So this is

one room and the intermediate care clinic, patients who are coming in. And again, circling all of the

risk factors that exist in the room, you can see that we're circling almost everything that's in

this room. So since none of these rooms are safe, what is it that we can do? Well, that's when we

have to rely on that one-on-one continuous supervision. If you've identified that a patient

is at risk for suicide, you need to keep eyes on them the entire time until they've been identified

to either not be an immediate risk or they have been identified as a risk, but we're actively now

getting them to a higher level of care. At National Jewish, we do not provide the level of care that

is needed for somebody who is actively suicidal with an immediate risk. So what we would do is

we transfer them via ambulance to either Rose or St. Joe's or possibly other hospitals. Porter and

Denver Health tend to have better psychiatric units and so does Children's, so we might send

them there instead of Rose or St. Joe's the closer to. So at all points in time, we have to watch

these patients because all those risk factors that we just identified, they're always going to be

there. We have to be aware that they're there and we have to watch this patient. Now, what if the

patient has to go to the bathroom? Well, we've got a policy for that also. Without their personal

belongings, there are two options for how a patient can use the bathroom. The first option is a same

sex staff or parent must escort the patient to a multi-stall restroom. So you don't have to go into

the stall with the person, but you do have to stay on the opposite side of the stall, be listening

and hearing and making sure that this person is safe. Now, some patients say, absolutely not,

I don't want that to be the case. Well, we do also have what are called ligature resistant,

single occupational restrooms. And right now at National Jewish, we have two of those.

So the first one is an A207A, which is our inpatient area. It's where the old behavioral

health floor was for pediatrics. It's in that hallway. And then also the Center for Outpatient

Health also has a ligature free bathroom. Again, around the pediatric behavioral health floor,

it's on T536. But please do remember, this is without their personal belongings.

Now you might be wondering, I wonder what a ligature free resistant bathroom looks like.

So on the screen, you can see there are two pictures. The picture on the left is our typical

bathroom. It is not a ligature free bathroom. You can see that there are a lot of risks. There are

hand bars that are there. There's the shower curtain. The toilet itself is actually not a

ligature free toilet. We have a plastic bag in that trash can. There's a lot of things. When we

compare it to the bathroom on the right, now this is the bathroom in A207A that is a ligature

free bathroom. Now this bathroom has very specific requirements all the way down to the type of

screws that are being used to hold things into the wall. They're screws that wouldn't allow you to

just take a knife or a pencil or a quarter to loosen. So we have to think about that as well.

You can also see that the door handle on this door handle, it's a little bit different in the

fact that if I try to put something over that, it's going to fall off compared to the door handle

that you might have in your office that you have today. Now some might say, and I do agree, that

it either looks like a prison bathroom or it looks like a bathroom that would be in an airplane.

I think that that's probably why airplane bathrooms look the way they do. The next time

you're ever on a flight and if you walk back to that bathroom, you can probably notice now that,

hey, this is the ligature free resistant bathroom. What is different about this ligature free

restroom? The handle on the door, the direction that the door opens. In that previous picture,

you maybe noticed that the door was opening into the hallway, not opening into the bathroom.

Patients and people in that bathroom are not able to block the door. There's absolutely no

hooks or towels. They do still have grab bars, but the grab bars are designed specifically that

you can't hook anything over them. There are no hanging points in these bathrooms.

There also is intentional that there are no plastic bags in the trash can. The trash can is

meant to not have a plastic bag in it. The sink faucet and the handles are different. There's

absolutely no way to wrap something around those sink faucets. The ceiling is different, so these

rooms do not have drop ceilings. They're completely flat ceilings. We have tamper free screws. We have

a tamper free toilet and also the toilet paper roll is a tamper free toilet paper roll that allows

it so somebody can't put things into it. And then the soap dispensers are also tamper free.

So you can see when we go into making a room ligature free, there are a lot of steps and

requirements to make that a safe environment for somebody to be in alone. Outside of these two rooms,

nowhere at National Jewish is ligature free. So you might be listening to this and be thinking

that, well, I can think of quite a few things that I think maybe we could change that are an

environmental concern in your area. So how do you report those? So you can go to our suicide

awareness page, which is on our spider web page. You go to the main spider web page. On the left

side, there's all the list of different categories. You go all the way down to suicide awareness. It

pops up the screen on the left. You're then going to go to the reporting section. And then in the

reporting section, the first link is the link for you to use to report any environmental concerns

that you have that you think proactively might be a risk to somebody who would be suicidal.

We want you to report these to us so that we can look and see, can we be proactive and remove a

risk for somebody? So in conclusion, we want to remember that National Jewish Health is not a

ligature free establishment. A patient who has been identified at risk for suicide should never

be left alone. I'm going to leave this open for any questions that might come through the chat,

or if you want to unmute yourself, feel free to unmute yourself and I'd be more than happy

to answer any questions that you might have. If not, I thank you all very much for joining us

today. We will be back in 2023. We're working on our different topics that we'll be covering next

year as well. So thank you all.

Thanks, Elizabeth. This was really good. Thank you, Peter. This really was. Thank you.

July 26, 2022

Determining Appropriate Levels of Care for individuals at risk for suicide

All right. I'm going to get started. So thanks for joining us today. I'm going to be discussing

levels of mental health care. And for those of you who do not know me, my name is Rachel

Stone-Cipher and I am a licensed clinical social worker here at National Jewish. So

I'm part of the social work team. I split my time between the cystic fibrosis team and

the adult general side. I've been here for about two years. I attained my graduate degree

at Denver University after completing my Peace Corps service in Mongolia. I've had the wonderful

opportunity over the 19 years that I've been a social worker to work in a variety of social

and behavioral health services in multiple states. I started my career working with families

that are involved with child protective services in Arizona. And then I moved on to overseeing

Medicaid and Medicare waivers for intellectual disabilities here in Colorado. My clinical

experience involves being an adolescent and family therapist, which then led to becoming

the regional manager for the same mental health agency in North Carolina. I was also a psychiatric

liaison between a managed care organization, which is very similar to what we call the

RAISE here in Colorado and at a local hospital in Raleigh, North Carolina. I then worked as an

emergency psych clinician completing psychiatric and detox evaluations to determine if they met

inpatient criteria or a medical admission for detox that was with the Nova Health Systems in

Northern Virginia. So I chose this topic to present due to my varied experiences with

different mental health agency providers and to give some insight on levels of care beyond

therapy and inpatient. So when people think of levels of care, they think of those. There's a

lot in between. So why would this be important to us at National Jewish? So honestly, this topic

probably won't apply to many, but I think it's most relatable to those that provide resources

and referrals for mental health providers. And for those that don't provide resources and referrals,

it's helpful to actually learn about these different levels of care to have an honest and

educated conversation with your patients about what their current services are, maybe what their

needs are, maybe a possible higher level of care. So it's kind of viewing that. And just to kind of,

I run into multiple patients too that we've come over to talk to about resources and they are,

they're involved with some of these community programs that are out there and most people

don't know what they are. So it's helpful to know where they're at and even patient where they're at.

So I'm going to start off with the levels of mental health care. And let's see. So I'm starting

off with the adult levels of care. First, I just listed what they are. So levels of care,

I listed them from highest level, meaning the most intensive, to the lowest level of care.

But sometimes they can be intertwined. So I always call it step up or step down.

So highest level care is psychiatric inpatient hospitalization.

Another program, these are kind of intertwined, it just depends. So the first one is a partial

hospitalization program, which is a PHP program. Sometimes this is intertwined with intensive

outpatient program, which is an IOP. And I'm going to talk about these each individually.

Another adult service is an assertive community treatment team, which is ACT. Of course,

medication management and individual therapy and counseling. So let's start off with the psychiatric

inpatient hospitalization. What is it? Basically, it's crisis stabilization. It's helping develop

coping skills. It's to be able to help find different ways for communication.

And it is when you are immediate at risk of hurting yourself or others. So we are not an

inpatient facility. So sometimes we do screens to determine whether or not the person needs an M1

hold to be able to get over to an emergency room for further evaluation. So that's what our M1

holds will do. So where does an inpatient psychiatric hospitalization evaluation occur?

So it's in an emergency room. And then who completes that evaluation? It's typically a

licensed clinician. I know when I worked for ANOVA, we were licensed clinical social workers,

we were also licensed psychologists, and we were also licensed counselors. A medical doctor can do

that, but it's typically a licensed clinician. So what is a mission criteria? That's a big thing.

So you're determining whether or not that person meets criteria for an inpatient stay. Typically,

if a person's like, oh, I'm depressed, I think about plans, but they don't have an immediate

risk or intent to do it, that's not a mission criteria for an inpatient stay, unless there's

some other things going on. So let's kind of review that as well. So like we said, when they

go to the ER, if they're having suicidal thoughts or thoughts of harming others, a clinician or the

doctor will complete a further evaluation. And so a lot of things, the other things we look at

criteria is kind of is what is the least restrictive setting for that patient? So maybe they could do

something a little bit more intensive, but they're not at immediate risk. So we're looking at that

piece. But so they have to be imminent risk of danger, or at least are grossly impaired by one

of the following. So they have to have had an attempt of suicide, active suicidal thoughts,

like in the moment with a plan, intent, and means to harm themselves. Or they might have had recent

threats of harms to others or aggressive behavior that would make them at risk to the community or

to themselves as well. Or also to life threatening self-medicalizations. I've had people that have

stabbed themselves in the necks, impulse control, impaired judgment, that's putting themselves in

danger. Even command hallucinations. So people that might be fearful of the hallucinations that

they're having, they feel like others are out to harm them, or they're having a voice tell them that

they need to harm themselves. And it can also be disorganized psychotic or bizarre behaviors

for them to function at a lower care, where they need to be in a facility that is locked and

monitored 24 seven. So also to sometimes medications can cause different life threatening side effects

that needs to be closely monitored. And the other one, too, we talk about this is gravely disabled.

So I mean, it's someone that's not functioning well, that is jeopardizing their safety and their

mental because of their mental health. So maybe not sharing, not eating properly, not sleeping.

Those are just kind of some of the things that occur. And let's see. So what does the psychiatric

admission entail? So it's compromised of the clinical team. So it's a multidisciplinary setting,

you have the psychiatrist, sometimes you have physicians, not all the time. You have 24 hour

psychiatric nurses, you have case managers and social workers in different type of experiential

therapists. So that could be like an art therapist or a music therapist coming in. So a lot of times

what it looks like in an admission is you have your assessment and your psychiatric evaluation

completed. So you have a full one completed again, once you're on the unit. And this is typically

done by the psychiatrist and monitored by the psychiatrist in regards to looking at medication

management. It's a collaborative approach. Like I said, all these people are involved,

they help the patient set goals. A lot of the goals are set around safety and how to maintain

in the community. And so their skills and strength based interventions that are provided primarily

in group settings. They do have the opportunity to talk to counselors one on one, but there are

a lot of groups that compromise throughout the day. So there's also safety planning.

That's a big one. And that's what we're really pushing here too is safety planning.

You want the person to be aware of their triggers, be aware of their safe spots,

being able to know that they're creating a safe environment for themselves. And also too,

big one is discharge planning. So you're looking at that transition to the next level of care.

A typical psychiatric admission can last anywhere from three days to about two weeks. They can go a

little longer, but a hospital admission isn't meant to be long-term care. It's crisis stabilization.

All right. So this leads to the partial hospital program. So sometimes this program, it's those

for mental and emotional disorders. And it's an alternative to conventional outpatient therapy.

So say it can be used as a step up or a step down. So if you're working with a therapist

and your needs are increasing, say you're seeing that therapist like two times a week

and you're just kind of, oh, I don't think that's enough for me. I need a little bit more,

but I don't have enough symptoms or I'm not at immediate risk for a hospitalization. Some

people may choose to enter a PHP program. So a lot of this is a group style therapy,

a lot of cognitive behavioral therapy to help learn extra coping strategies.

PHP programs, whenever I would have people admitted or stepping down or stepping up,

I kind of let them know that this is your job for almost the week. It is very intensive therapy,

therapy, different forms of therapy. And what it entails is looking at different things,

learning different coping strategies. So you do a lot of group work and it is looking at

self-interest behaviors, lack of focus, hyperactivity, boundary setting, problem solving,

depression and anxiety. So it also entails doing an intake of an assessment evaluation.

They want to make sure that you're going to be cohesive with the group and that you're there to

learn these skills. So it is, once again, a multidisciplinary approach. So it can comprise

of different therapists, it can comprise of psychiatrists and some other case managers

that might be helping. It's very patient directed. They're tracking your progress,

it's group sessions throughout the day. And then you typically meet with the therapist one-on-one,

maybe at the end of the day, sometimes in the beginning. And you also work with your

psychiatrist to see if there's any medication management adjustment or monitoring needed.

So a lot of times people from inpatient will step down to this program to continue what they've

learned during inpatient and to be able to help monitor too. It's kind of rare that people step

up from PHP, but every once in a while you will have someone that says, you know, I'm not doing

so well. Maybe I do need that inpatient hospitalization. Like you said, it's kind

of a nine to three, usually five to 10 days, Mondays through Fridays. So people that are

working, usually this isn't a good program for them unless they're able to take a little bit of

like time off for FMLA to be able to commit to this program. They're usually small groups,

eight to 10 participants. And it's just building on some of the strategies they might have learned

with their outpatient therapist or during their inpatient stay.

Okay. So that also leads us to intensive outpatient program. So what is an IOP? IOP is

very, very similar to a PHP program, but this one is a little bit more focused on substance abuse.

So when I used to work for an event, we would have an IOP program. And it was for those that

usually came out of our detox program, but it was still having some mental health concerns as well.

So IOP is pretty similar. It's not as intensive as a PHP program. So like down at the bottom,

the timeframe of the group, it's usually three days a week, three hours, usually in the 18 hours,

up to 10 weeks. So yes, it's long in that point, but it's trying to hold you accountable for your

sobriety. So they do regular drug screens, a breathalyzer, before almost every meeting that

you have or the beginning of that week. Once again, you have your assessment done, you have

the psychiatric evaluation, you're meeting with a psychiatrist, you're meeting with therapists

and different case managers. They're also medically monitoring you too. So I mean,

if you do have the drug screen and you test positive, you can attend the IOP group. It is

for continued sobriety and also learning the same type of sessions that you have during your PHP

group and working on different coping and relaxation skills, symptom management,

group therapies. So sort of, but more substance abuse based.

All right. So an assertive community treatment team. This is an ACT team. I think this is one

of the most underutilized types of levels of care that they have. Just because this is for

individuals that are diagnosed with serious mental illnesses. So those with schizophrenia,

different types of known for psychosis is a whole big team that meets you where you're at. So they

come to a residential setting, they can come to community locations, hospitals and outpatient

offices. So those are for those that have a hard time functioning in the community that needs a

lot of involvement. So you have a case manager that's part of the team. You have individual group

therapies, again, a lot of psychosocial education, possibly rehabilitation. They also help manage

medications too. So when I was a liaison with the psychiatric hospital in North Carolina,

I would often call an ACT team out to meet with an individual that has been coming in pretty

consistently. And I want to keep them in the community, but provide them with that support

and the services. So sometimes they help with housing. They're going to, they administer some

of the injectable medications as well. So if someone has a hard time with med compliance,

they're able to provide that service for them. Sometimes they act as the guardian melitum,

or sometimes rep payees to be able to help the person remain in the community without having

to go into a higher level of care. They do also to have like 24, they have crisis emergency teams

that will meet them where they're at too. So I think they are a great service. An example also

of an ACT team, Community Reach does have one and All Health Network has one as well here.

So medication management. This is one that people are probably a little bit more familiar with.

And this is a psychiatrist or a nurse practitioner that would do an evaluation.

They'll be able to prescribe medications to help improve the patient's symptoms.

So they will monitor them closely, have follow up visits, and adjust medications as needed.

All right. And this one, I think most people know about individual therapy and counseling.

So that is your basic kind of typically insurance will pay for 12 weeks of therapy sessions. So

typically weekly appointments. Sometimes if it's increased, you might want to see your therapist

twice a week. Sometimes you step down. So you've been doing good for about a month, maybe you

go to every other week in regards to the fee. It's where you're setting goals.

Therapists offer solution-focused counseling, cognitive behavioral therapy, motivational

interviewing, skill building, mindfulness. There's many, many forms of therapy. So some therapists

specialize in it. So when we get referrals on the social work side saying, oh, they need to meet with

the mental therapist, we appreciate calling them and talking to them about their preferences. Do

they have a gender preference of who they want to meet with? What's something they want to focus on?

Have they tried certain forms of trauma therapy like EMDR? What's their focus? What do they need?

And it can help us be able to kind of sort through some different therapists to find the right style

to meet the patient's need. So that's the adult side of things. I'll go into the children's side

of things. Any questions or comments or anything in regards to the adult side?

Okay. I will go to children's. So children's level of care is very similar to the adult level of care.

We do have two new things added in this one. So once again, we have the psychiatric and patient

hospitalization. We have a psychiatric residential treatment facility, which is a PRTF. We also have

the partial hospitalization program, the PHP, the intensive outpatient programs, IOP, and then

an in-home resiliency and support services. And once again, medication management and therapy

services and group therapy. So with children, it's very similar to an adult inpatient stay.

I would say the largest difference is you're doing more family meetings. I feel like a lot

of the programs do more of those experiential therapies, such as the art therapy or like

stretching or mindfulness and movement groups. But once again, you go to an ER,

and you are evaluated by a clinician. And you go to the unit, you meet with the psychiatrist,

they do their full evaluation. But family is definitely more involved. There's usually a

required family meeting at least twice a week, depending on how long your stay is, if not more.

But once again, too, I think the whole goal is looking at that discharge and planning and after

care. Sometimes though a child, they still have to be eminent risk. But some of the things that

they do look at is specific needs that are assisted with are aggressive behaviors, sleeping,

eating habits, depression, anxiety, panic attacks, phobias, bipolar, extreme mood swings,

prolonged sadness, schizophrenia, self-harming behaviors, sometimes unable to just plan for

their own health and safety. Also concerns related to trauma. Also looking at withdrawal

from friends. And then we're looking at, you know, what are these services that can't be

at an out-of-patient setting? So we need, if they can't function on an out-of-patient or on

that PHP level or IOP level, let's look at the next level of care. Once again, it is a shorter

stay. They're not long-term facilities and that's a little bit more about the PRTFs can be a little

bit longer. So I'll talk about that. So what is a psychiatric residential facility? So PRTF

is an inpatient psych facility. Just to let you know, this is only available for Medicaid

patients. They do not take private insurances at PRTFs. If you have private insurance, it would

most likely be an inpatient hospital, say. So this is a level of care where they just maybe not

quite meet the inpatient criteria. So a lot of times they say, kind of look at it like maybe

it's more aggressive behaviors, but they're not imminent risk to harm themselves. But it might be

some of those other key factors. They might be having problems functioning. They might have had

trauma. A PRTF is a little bit longer term. So is anyone under the age of 21? I did put the

website there that talks a little bit more about Colorado's PRTFs and what theirs looks like.

I've only honestly had experience with them in North Carolina. I've had patients stay,

and it can be longer than a month. Usually no more than three months will a kid stay there.

I think month is usually the max of what most PRTFs aim for. But you're also working with other

teams. Like I used to provide intensive in-home services. Sometimes our kids would have to go to

a PRTF if they're just not functioning well at home and they're being extremely disruptive and

you need to stabilize behaviors. Sometimes we would get referrals for kids just coming out of

a PRTF that we want to make sure that they're maintaining that safety in the home.

So PRTFs, it is a behavioral health 24-hour maintenance care. So it's room and board.

And they have nursing staff, a physician, and then they are referred.

Anyone can refer to a PRTF. Families can even refer to a PRTF, social services,

corrections, community mental health centers, and behavioral health organizations.

So, all right. And then we're going back to the PHP program for children. So once again, PHP,

these are for age ranges though for 13 and above for children. It's not effective for younger kids.

That's where the more intensive in-home stuff will come into play. They are a multidisciplinary

team again receiving their treatment. It does replace their time at school. So kidders, the

PHP programs work very closely with the schools to make sure that they're still getting their

schoolwork done and that they have a plan put in place. So they're going to coordinate with

the school to make sure that this is occurring because it is almost a two-week short-term intensive

program. So most kids that enter a PHP program are typically coming out of a PRTF or an inpatient

hospitalization stay. Sometimes they're stepping up from outpatient therapy. And they're doing

about the same things that adults do. They're learning different coping skills and how to

manage different behaviors in the home. Same with IOP. The IOP for kids is also for ages 13 and up.

And this one too is like they're trying to show how to be successful in the home and the community.

It's about eight to ten weeks. And once again, this one's about four days per week,

three hours after school. So these kids can remain in their regular school education program

if need be and then attend this after school. And it's also too for those any substance abuse

related disorders as well as mental health. Okay. In-home resiliency and support services,

IRS, is what we call it here in Colorado. I always called it intensive in-home services

in other states that I've worked in. But this one is for younger adults ages three to 21.

It is limited here in Colorado. Other states I've worked in, it has been statewide. I noticed this

is not quite a statewide service that is offered. But I know we do have them here in Denver County

as well. Adams County. I saw a pop-up. So I'm sure kind of metro area. I think high roll.

So this one is a trauma service. So anything, a trauma is an event that is involved in a death

or a serious injury or has threat to physical safety of self and others. So this is to help

support the family and the family members to create a support system. So it is a comprehensive

assessment. It's a combination of individual and family therapy. It is safety focused. So there is

a lot of planning and how to prevent with coping with crisis, coaching, skill building, and then

any guidance for community resources. I know when I did intensive in-home services,

I would have around five families that I would see. And I would see them anywhere from two to

three times a week. And they were two hour long sessions for therapy. So intensive. It's a kind

of a unique service. I think this one's overlooked a lot as well. And for IRS, a referral can be

from a community partner, mental health organizations, residential facilities, child

welfare agencies, hospitals, and schools. And it's helping increase that sense of safety and

helping to be able to help them improve their academic success and build better relationships.

So some of the IRS ones that are close are community reach and all health network. So those

are all in the Denver metro area. All right. Once again, we have medication management.

So typically a psychiatrist or psychiatric nurse practitioner can help prescribe medications. And

this one too, you know, medication management, like we said, is involved with PHP programs,

IOP, psychiatric hospitalizations, and outpatient services. So this is enmeshed in everything,

almost all services. And let's see in therapy services. So you can have individual therapy

with children, you can meet with them, same type of thing as the adult, probably up to about 12

sessions unless something else comes up. Group therapy is really popular with children and

adolescents because it's a good option for kids because they realize that they're not alone.

And it's also helping develop effective interpersonal skills. So a lot of child

therapists will also offer group therapy sessions too. Okay. So who can complete assessments in

therapy? So psychologists, licensed professional counselors, licensed marriage and family therapist,

licensed clinical alcohol and drug abuse therapists, and licensed clinical social workers.

And who can prescribe psychiatric medications? So a psychiatrist, there are child and adolescent

psychiatrists. And a big one that is becoming more and more popular is a psychiatric mental

health nurse practitioner. They are prescribers. And I'm going to give you some resources and

information. So as you know, a lot of times too, we hand out the suicide hotline. That is the hotline.

And now we have the 988. I know Elizabeth sent out a fast list in regards to that starting out.

Another popular one I used to like to provide was the crisis text line. So 741-741 is the crisis

text line. This is very popular among some of the younger adolescents that don't want to call and

talk to someone. But a counselor pops up on their text and they message back and forth until they

get to their call spot. It can be any crisis. But of course, if they are suicidal, they will send

someone out to assist. Usually that would be 911. We also have many, many crisis services centers

here in Colorado in every county. It's 24 hours to assist individuals. So I believe too that what

they do is if they do determine the person is at immediate danger or risk, they will have them do

an M1 hold and have them go over for further evaluation at the AR to be able to have placement

at a psychiatric and patient facility if deemed necessary. They have a text line. You can walk

into any other services you can call. So there's many different options and they are 24-7

in their confidential and they will provide you with helping you monitor that different

level of care that might be appropriate. Another one I really like is NAMI. That is the National

Alliance on Mental Illness. And this one I like to give to resources for family members that maybe

they don't understand mental health, maybe they're learning about it, they want other supports. There

a lot of free support groups through NAMI for individuals with mental illness or for those with

families or family members or caregivers of those with mental illness. They are also a great resource

too to call and ask about different styles of services in the area. And that's the same with

SAMHSA. So that's Substance Abuse and Mental Health Service Administration. So this is the federal

government's webpage. And so it has their webpage. It also has their helpline. This is a good one for

those that have substance abuse issues and they're having a hard time trying to find out placement

with their insurance provider. They can call here, find mental health services or substance

abuse services that take their insurance and that have availability in their area.

So just kind of to get an idea of who our local providers are is our two main psychiatric and

patient hospitals here are Denver Health and Porter and Fitness. So they're the most likely

where you would have an inpatient stay. We also have Denver Springs. They're in Parker and Englewood.

They have acute care. They have PHP, IOP and outpatient services. So they have all the levels

of care already there. Same with Highlands Behavioral Health Services is for adult and children.

And they have all the same services. That's in Littleton. And we also have West Pines. That's

another one that provides all levels of care as well. And Community Reach is the main one in this

area for any ACT teams. And so, you know, your local social workers here at National Jewish,

Elizabeth and myself, that is our numbers down at the bottom. So if you ever have any questions

about different levels of care or not sure what type of referral someone might need, you know,

and task us and let us know. Anybody have any questions? Any concerns?

Experiences they want to share?

Elizabeth, this is Nathan. I do want to ask you a question about

psychotropic medications that, you know, we have these patients coming in with long COVID that have

some of these pain symptoms, chronic pain symptoms. And sometimes psychotropic medications

are being used. Do you have a feel for who can prescribe those medications for those

pain syndromes? What's appropriate and what's not appropriate?

That's a great question. I really don't have too many answers of what would be appropriate

and not appropriate. I mean, normally what we do is we just look for different psychiatrists or

nurse practitioners or we refer them to a pain clinic if they're having pain. I would rather

have a pain clinic help assist with that because some of those drugs can be pretty heavy and have

it forming. So we're looking at different controlled substances versus non-controlled substances.

But yes, I think a pain clinic for pain is probably the best option

in regards to that. So I don't know if that helps.

Thanks.

Anybody else? Questions?

Thank you for the overview of all the resources. It was a great

understanding and clarification of what some of them are.

Absolutely.

The question is, can you give a little bit more information about this new 988 and how it should

produce? Well, it's just the 988. So in the comment section, the 988 is a shortened version

of the suicide hotline. So anyone who's struggling with suicidal thoughts

or feeling like they're in crisis, it's just calling 988 now instead of having to do the whole

long number for the suicide hotline. It's the shortened version. So it's the same as the suicide

hotline where you're calling. They're going to connect you to your local supports with the 988

and being able to talk through and just kind of see where you're at and assessing whether or not

you're at immediate risk of harm to yourself. And if not, then they're going to look at those

different levels of care and see what would be appropriate during that time too. So

it can be given to anyone and everyone that has suicidal thoughts. I know when we do evaluations,

we give out the number. So 988 can be the new number. It's just 988 to call.

And the text line is very similar. So some people prefer talking to a person live

versus texting. So they can also help provide local resources. So they'll get you connected to

your local members as well for the 741-741. I just know that the text line tends to be more popular

with the younger crowd. And they can assist with helping identify some of them. They might provide

like a referral to maybe the crisis center to kind of talk it out a little bit more,

let you know when they're looking at the different levels of care.

Good question so far.

Anyone else?

Okay. I don't see anything else popping up right now. So if you want to, feel free to reach out

to myself or Elizabeth. We are around. Do any of these services have a significant wait time?

So technically, no, that is a great question. So crisis services, I mean, I know when I worked

in the ER, the biggest thing was waiting for a bed to open on the unit and getting someone transferred

over. That can take some time, but they are in a safe spot and they're monitored. To get into a

PHP program or an IOP program, usually you can take a week or two. Sometimes people can get lucky

and they can get in right away depending on when the next cycle of groups are happening.

Therapist, yes, we have a mental health pandemic as well. So right now therapists are taking

very long to get into. Same with psychiatrists. Sometimes wait lists can be months.

So someone that's having maybe a little bit more of a crisis and needs immediate help might want

to look into a higher level of care like the PHP program or an IOP. PRTFs are pretty immediate.

In-home services for the kiddos, that one too is usually pretty quickly to get into. So the

longest wait right now is probably for a psychiatrist or to see a mental health therapist.

I typically, I know Elizabeth and I, we warn individuals when they're looking for a therapist

that there could be a while wait and it could take a little bit of time. So we let them know

that as well. And that's kind of where there's crisis lines too. If something is happening in

between, can come into play. All right. Anything else?

Okay. All right. Well, if you guys need anything, feel free to reach out to us,

the social workers and let us know. I thank you for joining us today and our

our lunch and learn. So I hope everyone has a great day and good rest of the week. Thank you.

April 26, 2022

Suicide in the US: Warning Signs and Risk Factors Among Patients and Providers, CJ Bathgate PhD
View Getting Help Suicide Resources (PDF)

hit start the recording for that part so you'll get the thing just letting you know and I see it

is recording for us but see today our speaker is CJ Bathgate she's a licensed clinical clinical

psychologist who works directly with the adult cystic fibrosis program here at National Jewish

to support emotional health and assist with the behavioral health changes that will help with

managing care. She will be presenting on suicide warning signs and risk factors for patients and

providers in the U.S. With that I'll turn it over to her. Awesome thank you so much let me

go ahead and share my screen so you guys can see the presentation.

So I thought I would start with some facts some did you knows and Elizabeth can you just confirm

that you see the big slide on the screen? Okay great so research from 2020 found that nearly

46,000 people died by suicide. Every 11 minutes someone in the U.S. dies by suicide.

When we look at Colorado data suicide is the seventh leading cause of death for people ages

10 to 64 and then when we look at the U.S. a little bit different of an age range suicide is

the second leading cause of death when we look at people aged 10 to 14 and 25 to 34.

Females attempt suicide twice as often as males and men die by suicide four times more often

than women and that is likely because firearms account for almost 50 percent of suicides and

females tend to use more non-lethal methods. Suicides and suicide attempts cost the U.S.

$70 billion a year when we look at lifetime medical and work loss costs and what I found

to be incredibly surprising is 45 percent of people who complete suicide actually see their

doctor in the month before their death. So there are things that we can do here that we

all should be aware of and first is suicidal thoughts these are a symptom they're a symptom

of something bigger perhaps depression and they can be treated and that means that they

can improve over time so just because someone is having suicidal thoughts does not necessarily

mean that they're going to act upon them it's our job though as health care professionals

to make sure that we ask the right questions and we start identifying certain things like

risk factors and warning signs so I'm going to focus my talk today on risk factors and

warning signs and they're a little bit different when we break it down.

So risk factors are stressful events situations or conditions that exist in someone's life that

may increase the likelihood of them attempting or dying by suicide it's important to understand

though that risk factors do not cause suicide and they tell us nothing about immediate risks

on the other hand though are warning signs. Warning signs are indicators of acute risk

for suicide and should be assessed immediately and what's most important here is that most people

who have completed suicide have given verbal written or behavioral warning signs so what

I'm going to do is I'm going to break down and talk about what are common risk factors

followed by what are common warning signs.

So when we look at risk factors I'm going to start at the top and I'm going to work my way around

clockwise and talk through some of these and these are the most common ones that research

supports so starting with the history or even current substance abuse physical disability or

illness which is particularly important in the population of folks that we see at National Jewish

right a lot of people come in with chronic health conditions comorbid pain there was actually a

study that came out in February this year that it was in the Journal of Sleep that found

persons with obstructive sleep apnea were at risk for suicide compared to a community sample so

these are people that we see here losing a friend or a family member to suicide can be a risk factor

and a huge one that I want to spend some time focusing on is ongoing exposure to bullying

or harassment and so related to this one there's been some research that has found that LGBTQ individuals are four times more likely to commit suicide than their

non-LGBTQ peers and I want to be clear that these individuals are not inherently prone to suicide

because of their gender identity or their sexual orientation but they're rather placed at higher

risk because of how they've been mistreated and stigmatized in society and additionally within

this category of bullying or being mistreated we've also seen increased risk among American

Indian or Indigenous Americans so we continue to move clockwise history of ongoing

mental health conditions particularly depression anxiety personality disorders

schizophrenia or prolonged psychosis that lasts over two weeks the recent death of a family member

or a close friend not necessarily by suicide although that does increase risk but just the

loss in general access to harmful means so this is related to the earlier slide particularly

firearms and drugs so with regard to firearms we've seen that veterans are at increased risk

because often they not only have access to firearms but they know how to use them

correctly and then among health care workers there's actually research that came out this

was back in 2010 that health care workers are more likely to use poisons as a means of suicide

because they have access to them at work relationship problems are another risk

factor and perhaps if we think about this more broadly stressful life events

like rejection divorce financial crisis and unemployment

now when we focus on providers some might say that suicide is an occupational hazard

for health care professionals and there are risk factors that make doctors nurses and other health

care workers more likely to attempt suicide than the average community member and these things

include long work hours right oftentimes unpredictable sleep deprivation and exhaustion

and when I say high demand situations this can be things like demanding patients

being on the front line of trauma working in the er or critical care that's a higher risk

because they're often dealing with a higher burden of death than having to make very quick

decisions about how they're going to care for an individual in an emergency situation

malpractice lawsuits medical school and graduate school expenses as I mentioned before the ease of

access to medication and then I think a huge one that we often don't talk about is the decreased

likelihood of seeking treatment for mental health and this could be something whether it be trouble

admitting that they might need some sort of support medically or psychologically I think a lot of

people have a belief that you know well I'm I'm a doctor I'm a health care provider I should know

how to deal with this and then they don't end up seeking help I know that people have also had

fears about how medication might affect their performance so that kind of stuff can come up

and then there's you know a higher risk of burnout and so burnout which is likely affected all of us

at some point during the pandemic we define that as it's a stressful it's a psychological condition

that develops when folks are exposed to stressful work environments and limited resources and when I

say limited resources I'm talking about insufficient workforce job uncertainty high job expectations

competitive work environments but also things like folks that have dual professional and home

responsibilities that might really stretch them thin on both personal and financial levels

so all of us are at increased risk now this is different though than warning signs right risk

factors are kind of an increased propensity towards you know engaging in suicidal acts but

are not necessarily indicative of immediate risk so when we think about warning signs these are

those indicators of acute risk and there is a mnemonic that I think can be helpful sometimes

people have this on their computer and it's is path warm and this can help you remember

some of the most important warning signs so I'm going to go through each of these and explain

what they mean so ideation ideation is thoughts or ideas of harming yourself or others for that

matter substance abuse is the s so this is noticing that somebody's got increased alcohol or drug

consumption purposelessness so this is just that loss of purpose and self-worth anxiety which can

be just overwhelming amounts of fear and worry feeling trapped so feeling like there's just no

way out of a current situation hopelessness they just don't have any hope for the future

withdrawal so removing themselves from a social interaction canceling a lot more plans just being

a bit more reclusive anger so showing increased aggression recklessness so this is engaging in

abnormal activities without regard for any consequences and then mood changes so having

frequent mood swings now when we think about risk factors and warning signs it's important to also

remember that there are protective factors at play and so when we think about protective factors

I'll also go around clockwise and there are a handful of things that really surround adaptive

coping that can protect somebody from resorting to suicidal attempts so this starts with just having

an overall resilience I think that a lot of our folks that we see here they do have resilience

they've been through the wringer trying to figure out what's going on with them and you know many of

them have this sense of heartiness that keeps them going and keeps them coming to appointments

having effective problem-solving skills so noticing when things feel overwhelming and being

able to break this down into smaller more manageable pieces so that they don't feel

overwhelmed with everything all at once and feel trapped having both an awareness

and access to both physical and emotionally supportive care so sometimes people don't even

know where to go when they're experiencing these symptoms so when people have an awareness

that's step one and then having that access to care is step two having positive peer and adult

relationships that's important because even a single source of social support can buffer stress

being in a safe environment so for example having limited access to legal means

feeling a sense of connectedness right that you matter that you've got a community around you

that can help you out when you're not feeling like you can stand on your own at times

having cultural or religious beliefs that discourage suicide can also be

protective and so when we look at these positive protective factors I think you can see that all

of these things can fluctuate depending on what's going on in someone's life so it's important

that programs out there to support and maintain protection against suicide should really be

ongoing so just because we've asked somebody once and we know that they have one of these things

doesn't mean the next time we ask that they will. So as a recap and then I'm going to talk about

what we can actually do I want to remind everybody suicidal thoughts are a symptom which means they

can be treated and improve over time right risk factors are the conditions whether they're

stressful or just particular situations that are happening for people that exist and increase the

likelihood of them attempting or dying by suicide but it doesn't tell us anything about immediate

risk that those are the warning signs that we talked about that we should assess immediately

and so what can we do both for our patients and for ourselves and our colleagues I think that

is really important for all of us to understand and know that there are places to turn so first

especially when we're thinking about conversations with others don't be afraid to ask about suicidal

thoughts asking about suicide does not make it more likely that someone will do it it does not

plant ideas in their head frankly if somebody is at that point they've been thinking about this a

lot and sometimes it's a relief to have somebody understand them and ask them some questions about

it remember going back to that first fact 45 percent of people have actually seen their doctor

in the month before committing suicide so it's our responsibility as health care professionals

of picking up on some of these warning signs or we know they have a bunch of risk factors to ask

in addition to your patients it's important to just check in with your colleagues right

just see how they are and you can remind them of the different resources that we have which I'm

going to present on the next slide you know it's okay to not be okay and to let somebody know that

and to let somebody know what they can do in order to help themselves as a community and as

an organization we can work towards reducing burnout and some things that you can do individually

is to create space for yourself and take what you need if you don't do this somebody else

is not going to do it for you so you know if you feel like you are stretched really thin

it's important to set these boundaries create that space for yourself to take the time

for whatever you need when we set boundaries it's learning to set work down for other commitments

work is incredibly important to a lot of folks listening if not everyone listening right so are

some of the other things that are going on in your life and so sometimes those other realms of our

life may take a priority over what we're doing here depending on the situation so allow yourself

to set that boundary acknowledge your limitations so this saying is one that I think sticks out in

my mind whenever I talk about this is don't keep burning yourself to keep others warm

we are all compassionate and we all want to help and oftentimes that comes at the expense of our

own self-care so it's important to make sure to take care of yourself because when we can take

care of ourselves and reduce burnout we are so much more effective and honestly more pleasant

to be around with our colleagues find work off work outlets and stay connected to

your social support network so you know seeing your colleagues is great out of work

it's also important to see people that have nothing to do with work as well

um keep appointments with your own doctors to maintain your health both physical and emotional

and consider some professional support which i'm going to talk about and i'm going to break

it down by category that each of you have access to and it's free so in the left column

um this is who can access the particular resource um the resources listed in the

middle and then the contact information for the resources in the third column so

what i want to make very clear with the colorado health program with the peer health assistance

programs with the support link with all of these when you reach out to them it is confidential

they do not come back to national jewish and say oh hey did you hear so-and-so called us that does

not happen uh when we look at why this is broken down it's they have particular people that are

used to working with mds and physicians assistants with nurse practitioners and psychologists

the employee assistance program here is quite extensive in that they even have an app that goes

along it with uh texting personalized coaching self-guided resources they offer five no cost

counseling sessions they have legal consultation there's all sorts of things that the employee

assistance program can provide and that's available both to you and members of your immediate family

and i think we need to just take a pause and um kind of get over that inertia

you know this this difficulty asking for help right we want to be effective in our jobs and so

that means we have to take care of ourselves now the only time that somebody at national jewish

would know if you go to one of these programs is if your boss or somebody um in hr or something

like that says you need to do this they do not know if you voluntarily access because if you

need to do something they'll just get a very brief overview of like yes this person has sought out

support if you do this voluntarily though they will never know that you've reached out they won't

even know your name national jewish does not get a list of people that have access to the employee

assistance program i think that's just really important for people to know because i know some

people are worried about what if my employer finds out you know are they going to judge me

for this your employer is not going to find out the program is there so that you can access it

now if you are impaired and you're functioning and your ability to take care of patients or do

your work and you are recommended or required specifically i should say required to do this

then that's when they get the feedback but if you're recommended or you're doing it voluntarily

they do not this they also get any information if you need some sort of accommodation

right so um again that's the only time the information would be released so just

to really hammer home self-referral is much different than a required evaluation

the required evaluation is there so that they have something written down that says you're safe to

go back to work but other than that everything is confidential these last two resources the

colorado specific with the crisis services and then the national suicide prevention line you

can text them you can call them they are available 24 7 and they can help guide you to additional

resources in your area that can be of use so that is all i have for today i know that this is being

recorded so if you ever want to go back to this to take a look at this you can i can also

send out this slide i can have elizabeth send it out if that's something that you guys

might be find of use

and i think with that i'm going to wrap it up and turn it back to elizabeth so she can let you know

about some of the other upcoming quarterly events that are happening

thank you very much so the next this is a quarterly suicide learning collaborative so we'll be back

in july so the next one is going to be on july 26 and it's determining the appropriate levels

of cares for individuals at risk for suicide and that one is going to be conducted by rachel stone

cipher she happens to be sitting right next to me she's one of our licensed clinical social

workers here at national jewish health with our cf and some of our adult clinic as well too

and then we'll be back in october for making a safe environment please be aware of our spider web

page so you can go to spider web on the left column all the way at the bottom there's a section called

suicide awareness you click on that there are links to other education opportunities there's

recordings from last quarters zero suicide initiative and then also there is going to be

this one there's written information for you there's information on how do you chart about

patients there's just a lot of great resources that will be on there and that website is going

to be updated on a regular basis so every once in a while i'm taking a look at it one of the new

things that you're going to get a fast blast maybe later today or tomorrow about is going to be who's

required to let us know when they've done suicide evaluations so that will be coming out

and that's also where you can do that evaluate do that reporting of any evaluations does anybody

have any questions that they would like to put in the chat or if you'd like to unmute yourself

before we say thank you for attending today and see you all in another quarter

all right we don't see any coming in but i think one of the key things that cj was talking about

is if you need to or if you're concerned about patients please speak out that's the big goal we

want people to talk and we want you to get the resources so i hope you all have a great rest of

your day thank you

January 18, 2022

What is Zero Suicide and How is it Implemented at NJH? - Elizabeth Langhoff

Good afternoon, everybody. Welcome to our very first suicide awareness virtual learning collaboration. Glad that we can have so many people joining us so far and I'm sure a few more people will be joining us.

My name is Elizabeth. I'm the licensed clinical social worker for the adult clinic here at National Jewish Health. And I'm also the person who they put in charge, I guess maybe I'm a chair we didn't really give me a name.

I'm just the person who's in charge of our zero suicide initiative here at National Jewish.

So today we're going to be talking about what is zero suicide and how is it implemented by everyone at National Jewish Health. I am recording so you can see that it's recording, we're going to talk about this great new feature that we have here at

our spider web page and where this video will be replaced on there, so that people can join us later down the line and rewatch this video and learn what zero suicide is as well.

I have muted everybody so at the end I do have time for questions so feel free at the end to jump on with questions you can also use the chat and we'll get to those questions at the end as well too.

So I want to start a little bit first with what is the history of zero suicide and what is going on when I'm talking about zero suicide. So zero suicide is a program that started back in 2010 and 2013.

It was the result of a partnership between the National Action Alliance for Suicide Prevention and the Suicide Prevention Resource Center and other national suicide prevention experts from 2010 and 2013 a task force of suicide prevention experts got together and during

that time they developed and launched what would become zero suicide that we do here at National Jewish today, and it's a national program so it's done throughout the entire country.

Their effort revealed that there was deficiencies and the identification and treatment of suicidal people receiving care within healthcare organizations and opportunities to improve that care based on the emerging experience and research findings.

So when they started doing this they started noticing that there were things that were going on throughout hospital institutions, and that if we did something differently it was preventing suicide deaths and they wanted to come up with a.

They call it a work plan for us to go through and to initiate that work plan here at National Jewish. The foundational belief of zero suicide is that suicide deaths are preventable in the healthcare system.

So, as healthcare employees when we're working here at National Jewish health, we have the ability and the power to prevent deaths by suicide.

So I think a lot of times when we think about suicide prevention, especially in a hospital setting a lot of people might be thinking, well this definitely makes sense when I'm actively working with patients, I'm the one who can have that impact.

And you absolutely do, but that's not the only individuals who have this impact on zero suicide and preventing suicides.

So, why is this important for those of us who don't work directly with patients. So you might be wondering, asking, why was I also invited to this when I don't work directly with patients.

The first one is that everybody plays a role in suicide prevention, regardless of what your job title is if you have experience with patients or you're not working with patients we all have an impact.

One of the things that you can do is you can assist us by identifying the environmental concerns that we have here at National Jewish. So if you're walking through the hallways and you see something that would be concerning especially if I was somebody who was having

thoughts of suicide, you can let us know and we're going to talk about our now resources that we have for people to let us know about these concerns.

The next thing that you also have the ability is, we never know when or who will be brought into a suicide crisis and working in a healthcare system increases your likelihood of interaction with a patient who may be in crisis.

So, for example, the one I always like to use especially in the suicide awareness and response training is, you could be going to the bathroom, and you could run into somebody who's crying in the bathroom on the floor.

You need to know what to do and how to help this patient at that time. Patients don't just look at our name badges and just look for your job title to choose to be the person that they're going to reach out to for help.

So by training everybody and acknowledging that this is not just the clinical staff but this is everybody who has an impact is very helpful in preventing and the goal of zero suicide.

So let's talk a little bit about zero suicide and why it's here at National Jewish Health. So zero suicide is a measure that we started doing in 2021 we have actually been doing it for a little bit of time.

So started at the beginning of last year. It's a HQIP measure and HQIP stands for Hospital Quality Incentive Payment Program.

What basically has is there's different parts of zero suicide that we work towards, and when we meet those parts, we get incentives for making those parts. It's a quality improvement plan as well so we can see hopefully growth and the positive direction of how are we helping our patients who are having suicidal ideations during that time.

It's a four level program that we're going towards and we're going to talk about each of these four levels of the program.

So this is just for those of you who like the math side of things we do actually get scored for each of these levels that we reach in zero suicide, but the overall goal of zero suicide is so that we have a program that is effective and helpful for patients who might be experiencing suicidal ideations.

So I mentioned that back in 2010 to 2013, this group of individuals got together and they came up with a program framework to show that when this occurs and happens, that there is help and better services for patients who are experiencing suicidal ideations.

And they adopted a framework that has some evidence based elements in it. So they saw that using specific tools things along those lines help. They saw that when hospitals collected their data to try to learn from their outcomes that that was helpful.

And that when we use quality improvement to recognize where our weaknesses were and to try to improve at those that there was help. And then to also normalize suicide prevention so making it a part of everyday conversation that's going on.

And so that families expect this as a standard of care that when we are here at National Jewish talking about suicide could be an everyday occurrence that were happening and they feel safe having that conversation here.

There are elements that are also associated with zero suicide. So those elements include leadership buy in training, identifying individuals who are at risk, engaging individuals who are at risk in their care management plans to provide the proper treatment to provide

transition. And so, at National Jewish health, we don't meet the criteria of care to have a patient here who has active suicidal thoughts and an active plan and somebody who needs to be transferred to a higher level of care.

So how do we make that transition a smoother transition between National Jewish health and elsewhere that we're sending them to. And then of course, all quality improvement is about that improving. How do we get better over a period of time with working with patients who are suicidal.

So the first part of zero suicide is the leadership and planning part, wanting to know that there needs to be somebody at the top who is guiding this and who supports it.

So the first one is that leadership buy in this program does have buy in from the highest levels here at National Jewish including Dr Horn is on our implementation team.

We also did a self survey we did this back in December, and we did a workforce service survey some of you maybe actually completed this survey for us. We're going to talk about it a little bit more in detail but also I think what's really great is since the last time it was

a year ago, we almost doubled the number of previous participants who were taking this, which to me shows that we're starting to acknowledge and recognize that zero suicide is a part of national Jewish culture.

So I mentioned that there's also an implementation team so this implementation team is a really the task force here at National Jewish that is focusing on our policies.

How do we get zero suicide international Jewish health, and how do we make sure that our buildings are environmentally safe as well.

And that's what the zero suicide implementation team is for, and you can see here on the list this is the current number of people that are on our implementation team we call it our suicide awareness council here.

There are clinical and there's non clinical people on this team and we want more people on the team. So this is something that you are interested in joining if you have a passion for this topic and you want to help support our endeavors.

I encourage you to join this team.

And I'll show you how you can do that as well.

What is the point of the suicide awareness council so the implementation team is charged with the task and roles to have scheduled meetings, so we meet at least quarterly, and we have been meeting as needed in addition so we've had a little more than quarterly

meetings but at the very least we have to meet quarterly.

We meet individuals who change the policies and procedures associated with suicide intervention and assessments.

We do evaluation plans to assess the impact of how zero suicide is working here at National Jewish and how our policies are helping our patients.

And then we're responsible for the quality improvement and the development of all specific approach to measuring and reporting on all suicide deaths.

So the second third part of our zero suicide level one the leadership and planning is to do an organizational self study. So these members of the implementation team get together.

And we actually go over how are we doing at National Jewish Health, and how do we think we can improve from what zero suicide tells us is best practices so are we meeting those best practices, but it also includes additional things for example, we attend

zero suicide learning collaboratives that are hosted by the Colorado Office of Suicide Prevention. So there's trainings that members of our staff are going to every single month to learn from other hospitals.

And in fact, today you are in one of the things that came out of that meeting so at the VA, the VA does a quarterly learning collaborative as well and so that's where we got the idea to start this learning collaborative to help reach out to staff.

And as I already mentioned completed our self study. We also do literature risk assessments and these are completed on a regular basis throughout most of the patient areas we try to get to all the patient areas.

We go through National Jewish Health and we specifically are going through and thinking about our patients who might be at risk for suicide or having suicidal ideations.

These are the things around us that could be a concern for that individual so that we can identify them and make changes where appropriate. One of the biggest things we do here at National Jewish to make our environment safe is when we identify a patient who is suicidal,

we don't leave them alone. So we would always encourage and that's part of our policies that we don't leave this patient alone.

This next one, the work plan. So the work plan is actually our goal for 2022. So something that we're going to the implementation team will be doing in 2022 is a SWOT analysis and environmental scans of where can we improve and what strengths do we have

here at National Jewish when it comes to helping our patients who are suicidal.

So that's the first part is that getting management involved having an implementation team of zero suicide. The second part of zero suicide is training, and how do we get our staff trained.

We acknowledge and recognize that even health care providers who have gone through lots of years of school. When it comes to suicide, they might not actually experience that much training. So we offer and are offering resources for our staff to learn.

So the first part of that training is our workforce survey, which has been completed. Thank you to the 190 of you who participated.

These results have already began to direct the focus for the council over the next year, one being this and then the website that I'm about to announce here in a little bit all came out of that workplace survey.

One of the things that you all told us in that workforce survey that you wanted was more education. So we're here to provide you education at least on a quarterly basis. And then we will be discussing some of our already existing training that we have as well too.

So things that came from this work for survey became our spider web website that we're going to be going over and I'm going to be showing you our policy changes that we already have started that will be implemented by 2023, and our training opportunities.

The second part of zero suicide in the training level is non-clinical workforce training. So zero suicide wants to recognize that even if you're not a clinical individual but you're working in a hospital, you also need training to help patients who may be suicidal.

So here at National Jewish one of the biggest ways that we're doing that is our suicide awareness and response training.

We have encouraged recently our admissions, our security, our radiology, our financial counseling, our pharmacy and our HR department to start attending these meetings, these trainings, but everybody is welcome to attending these trainings.

We also do have our clinical workforce training. They separate them when it comes to zero suicide. So the clinical workforce training also has the suicide awareness and response training.

But we also are going to be adding the suicide awareness as part of skills review for nursing in this upcoming year.

So I mentioned a lot about the suicide awareness and response training. So what is that? The suicide awareness and response training is an internal training that was designed by National Jewish Health for National Jewish Health to help staff know what they need to do when they have a patient who is suicidal.

What are our policies? How do I help them? How do I talk to this patient? It is a two hour in person training. We will only do this training in person. There are specific reasons for that.

But I'm not going to get in that today. If you're curious about why we only do it in person, I always encourage you to give me an email and I can talk to you about it.

It was specifically designed for all staff to be able to attend this training and understand the training and benefit from the training.

One of the main goals is it reviews policy. So it goes over what are you to do here at National Jewish and how do you get the support that you need.

Currently, it's available twice monthly, but we can also arrange additional training. So there have been times where myself as one of the instructors, a department said, you know, those times aren't really working.

It would be easier if I got my entire department together at one point in time to do the training. We can arrange for that to occur as well, too.

Right now we are considering social distancing. So we would have numbers that we would want to not want to be over, depending on the room size.

So we could still, however, do additional trainings if you're a manager and you want to get your staff through this training.

So why should you attend this training? So these next slides are going to come out of our workforce survey that we did.

So we found we actually were able to divide our participants who attended that survey between people who had taken the training and individuals who had not taken the training yet.

And the benefits we saw was there was an increased knowledge of our policies here at National Jewish Health.

They felt like they were more able to recognize somebody who was at risk for suicide.

They also felt that they had more confidence in their ability to respond to patients who were at risk.

They were more comfortable in talking to patients. It's hard, especially if you've never done it before, to sit down with somebody and talk to them and ask them if they're having suicidal thoughts.

And one of the main parts of this class is to give people the opportunity to actually practice that and give them this safe environment for the first time they've maybe ever said those words to be able to do it in that area.

So that's our suicide awareness and response training. The other thing from the workforce survey we had was that people wanted more education.

They said that they would want to attend education that's occurring. So with that and from VA giving us this wonderful thing, you already are at one of the first things.

This is our new National Jewish Health Suicide Awareness quarterly, virtually learning collaborative. And we already have 2022 planned of what is going to be happening over the next year for this learning collaborative that you're attending today.

In April, we're going to be talking about warning signs and risk factors. Dr. Bathgate is going to be doing that for us. In July, we're going to move on to determining appropriate levels of care for individuals who are at risk.

Our social worker Rachel will be doing that. And then in October, Lisa from our quality improvement program is going to be talking about how do we make our environment safe for people who are at risk.

So you'll see emails coming up in the next over the next year. We're going to be doing this quarterly and our goal is to continue doing this over time.

The next part that we're going to go over is we have and I'm happy to announce that we have actually formed and made a National Jewish Health Suicide Awareness spider web page.

My goal was to have the link available on spider web during this presentation, but IST is still working on it. So as soon as IST gets it on there, I will be sending out a fast blast about it so that you can all see it.

But I want to go through I'm going to pull up the actual website, because I want to show you what is actually on this website, and we're going to go through it so you can see how helpful this is going to be.

And I can see that you all can see the website, because I have a second computer in here that I'm using as well.

So this will be found on our spider web page, I will in that fast blast I will let people know exactly where it's at on the spider web page so that you can find it.

This is designed for again, all staff to be able to come to this website, when I have somebody who's in front of me or if I am just wanting to learn a little bit more so I can be prepared for somebody who's coming in front of me, so that you know what to do.

So you can see on our first page we have an overview here of quick links, the top things that are going to be needed when you're working with a patient who is suicidal, and a little bit more of just what is all involved in this page.

The second tab here, your suicidal patient next steps tab is going to be one of the most important pages that you're probably going to want to come to, because it actually is going to give you step by step guides of how to help somebody in front of you who's experiencing

suicidal ideations and thoughts. And this is for all patients at National Jewish Health is for people who are on the phone. It helps for those who actually do the evaluation piece here at National Jewish what are some things that you need to do.

What are the important documents that you need to get at. I'm going to open this evaluations one here.

You can see that you can actually download this form. I know especially on a presentation it's a little bit hard to see, but this is a Columbia Suicide Severity Rating Scale, and this workflow shows you every step that you would need to take while you're doing this with a patient.

There are a few who are not the evaluation piece which you can see that our evaluators here are licensed clinical social workers, licensed professional counselors, physicians and psychologists, but everybody else at National Jewish also has a role.

And your role is this assessment part so you can see here that again it gives you step by step, what to do, and who to call if there's a concern.

The second part of this section is our important documents section. So when you're working with a patient and you need documents right away, you can come on to this new spider web page and be able to find all of those here.

This section is our policy section that you can see on here. Again remembering that National Jewish is not a designated facility to care for a patient who meets the criteria for an M1 hold.

So if a hold is instituted, the patient must be transported by ambulance to an emergency room, and so this policies cover how do we get patients to the appropriate level of care, but our suicide and assessment and intervention.

For those of you who don't know right now National Jewish is in the process of changing our policy making program to another one. So right now these are not links to the policy but once that changeover has happened, this is actually where you can come to

immediately find the policy and just click on the policy.

But we also will have a section on here about what is zero suicide, and who are suicide awareness Council members at National Jewish, so you'll be able to come on to this website to get a little bit more.

And also will give you the option if you want to email us about something you can have the option here to email us and get your feedback or get suggestions or help from us as well.

So the next section on our new spider web is our section about reporting. So, reporting is a requirement of zero suicide it is something that we need to work on. And this reporting is one reporting environmental concerns that you see so if you're walking

And you notice if there's something that just doesn't seem safe if I was somebody who is suicidal, you can report it and you can let us know that that's there so that we can evaluate it and see what changes need to be made.

The second part of it is to actually report when if you are somebody who has completed a suicide evaluation that you can tell us that you completed a suicide evaluation and we're going to go over a little bit more as well to what all that is including.

This is only for completed evaluations, this is not a section for you to use to request evaluations. So you'll have that easy access on this page to to let us know I've completed a suicide evaluation and what has occurred.

The last section on our suicide awareness spider web page will be our education section.

So you can see that we have some definitions.

We have some basic information about warning signs of suicide and the risk factors of suicide.

But in this section over here you also see we have charting examples we're giving you what you need to do when you worked with a patient who is suicidal what you need to chart.

This section has the quick links to the different resources that we would like you to use while you're doing these evaluations.

And these are fictional, they were made up of somebody who needed to be transferred to a higher level of care. And then we have somebody who's not an active risk, but we still needed to do some support for this individual and we give you the resources

there as well as how do you chart for this individual to.

This section also gives you training opportunities not only external training, but also internal training opportunities. So there's the information here about our national Jewish suicide awareness response training that we already talked about.

Another recommendation from us and if you are working with an inpatient is to use a Columbia suicide severity rating scale. And there's an offer a free 30 minute training from the makers of that scale.

And this link here gives you that opportunity to complete that training and learn more about how do I use a Columbia suicide severity rating scale, and how do I have that conversation with a patient.

This is also where we'll be, you may be noticed at the beginning of this class that told you just to be aware this is being recorded. This is where you'll find future recordings of our presentations or slides associated with them, and then the updating up the dates for

the future trainings that we're going to be having from our learning for operate collaborative.

So we're going to exit out of that and we're going to be back on to our slideshow. So that spider web page as soon as IST gets that link on there for me, I will be sending out a fast blast so that everybody has access.

They know where to find it on our spider web page. That is a page that we put together, due to that workflow survey and seeing that it was something that was needed.

So this third part of zero suicide so we've talked about the leadership, and we've talked about the training aspect. The third level is how do we identify, treat and engage people who may be suicidal.

We have guidelines and ways that they want us to do this in zero suicide. So one of them is to screen patients here at National Jewish, we currently screen all of our inpatients who are over the age of 12, upon admission, using something called the ask tool.

This is a screening tool that's done by the nursing staff upon admission. We do make sure that that screening is occurring as well to the next part is an assessment here at National Jewish we're really calling our assessments are evaluations.

So it's one thing to screen a patient, but if a patient is positive. How do we help that patient after they're positive from their screening. And so right now we are tracking what happens to patients who screen the positive, and where they go from here where we

need to send them to a higher level of care. We currently are doing those that the adult social work team is notified of, but we need your help and we're going to talk a little bit more in the presentation to about how we can get your help, and we did just talk about it.

So you saw a new spider web page about the reporting section.

Another part of the zero suicide level three is a part called safety planning so when you're working with a patient who is suicidal, but they're not an active risk meaning that they don't require immediate believe being sent to an emergency room, but they still need support.

So one of the things that zero suicide wants us to do is to do safety planning with these patients, it's also a part of best practices. So this is not something we're currently tracking they want us to track that we've completed the safety plans.

And in fact, it's not really a part of our policy right now. However, this is one of the policy changes that we're going to be implementing in 2022 is so that those individuals who screen positive or suicide risk, but are not immediately at risk.

They'll have a safety plan that's initiated when appropriate by our staff, and that safety planning will be done by the individuals who can do evaluations.

The fourth part of zero suicide level three is are engaging, and this involves engaging other institutions outside of national Jewish health on being involved in what is happening with our policies, getting ideas and feedback from them as well too.

So the implementation team will set meetings with different caretakers around the community, and getting their feedback and support from them as well so that this isn't just what happens that national Jewish, but we're getting that from everybody.

There's the fourth level of zero suicide. This is the last level of zero suicide. The fourth level of zero suicide is called our transition and improve section. So one of the first things that zero suicide wants us to be doing is follow up.

Zero suicide wants people who screen positive to have a follow up contact from national Jewish health within three calendar days. Right now, this is not part of our policy, and it's not going to be our focus for 2022.

We have some other things that we fill our priorities over this first. So this might be something a few years down the line that we can take a look at but for right now, this is a part of zero suicide that we won't be doing.

We're being transparent with you guys with what we are doing and what we're unable to do at this time.

The second part is zero suicide wants us to track numbers. For those of you who work with tracking and identifying things. The reasons why it's important to track numbers is so that we can know what changes are happening.

What's being done correctly? What are ways that we can improve? Are we doing all the parts of best practice to help patients who are suicidal? Currently, we're only tracking inpatients at 100%, but we need your help because we also want to track all of our outpatients at 100% as well.

So if you are somebody who completes evaluations, again, that's our licensed clinical social workers, our psychologists, and our physicians. If you're one of those individuals, I'm especially talking to you right now, we are wanting you to help us identify completed evaluations.

So this is a new red cap that we have, and you can get to it from that spider web page on zero suicide. It was under the reporting section. And when you go to that reporting section, you're going to click on that link and this suicide tracking form is actually going to come up.

So you can see that it's going to ask what was the patient's name and the medical record number? What was the date that they received their evaluation and who completed their evaluation? And what are your credentials?

Now, the reason why we're asking who completed and what are your credentials is so that we can get a better idea of who at National Jewish Health right now is already actively doing these evaluations. So we are wanting to get that feedback from you.

The seventh question in our tracking form is a little bit more of trying to get to the how do we standardize our care here at National Jewish? What tools did you use? What actually happened to this patient? Did they need to be transported out of National Jewish?

Or were we able to do their safety plan here? Where did we provide them with mental health providers? Did we provide them with the National Suicide Prevention Hotline? And then the eighth and last section of this new reporting red cap system is other comments.

So if you feel that something happened that you could have benefited if we had resources for this would be a perfect area to give it to you. These aren't always as cut and easy as we'd like them to be when we're actively doing these evaluations.

So did something occur during it that you need us to be aware? That's what that other comment section is for as well.

So I'm going to now open it up for questions. I'm going to check the chat section. I did not see that there were any questions that came up in the chat section. Does anybody who's joining us today have any specific questions that I maybe didn't get to answer about what is

What is zero suicide and how are we implementing it here at National Jewish? I'm going to open that up to the floor now.

If you also want to unmute yourself, you can do that as well, but the chat is there and available for you too.

I don't see any questions that are coming through. You're more than welcome. Thank you for the compliment. At least I know that it's working. So thank you guys for letting me know that it's working as well too.

This first learning collaborative really was to get an idea of what is happening at National Jewish Health. So I do see now what are environmental risk factors.

So I'm going to learn how to speak at the end of our presentation today. Environmental risk factors are anything that is at risk to somebody who might be suicidal.

One of the easy ways to do it is when you sit in your office and you look around your office, essentially ask yourself the question of, if I wanted to hurt or kill myself, what in my office could I use to do that?

It could also be things like, is there a door to a roof that is unlocked? Because we don't want somebody getting that ability to get out onto a roof.

So it's really thinking what is dangerous around me, specifically for somebody who already is having thoughts of wanting to kill themselves.

So those are some examples of environmental risk factors. And Lisa will also, that's a great question. Lisa will cover that in October. Sarah, I hope that answered your question for you.

Let me know if you have more, want more examples. We do also talk about it in our suicide awareness and response training. It's a very long list of different things that could be a risk factor.

And so that's why one of our main policies is identified patients do not get left alone because we are not set up to be a place where a person who is suicidal can be in a room by themselves.

So thank you for the question, Sarah. I appreciate that.

I don't see any other questions coming in right now, but I will leave that available.

Tobacco cessation coaches and CSR do these evaluations often. Would we have access to this form? Yes, you do. That is why we made the spider web was so that people didn't have to go into the policies to pull out forms.

The spider web page is going to be available to everybody at National Jewish Health. If you're having issues with getting into that spider web page, we want you to let us know so that we can contact IST and IST can make sure you can get access to those forms.

So it's not something you can Google and pull up National Jewish Health spider or National Jewish Health suicide awareness page, but from our spider web page, you will have access to it.

That should include patients going to be our alone. Yeah, it should. To Gwen's point, patients with active suicidal thoughts should not go to the bathroom alone unless it's specific, a specific liquor safe bathroom.

So this is a really great point, and this is actually something you'll find on that spider web to under our suicide intervention and assessment. And we talk about it at the suicide awareness and response training.

Our patients can't go to our bathrooms by themselves if they're already been actively identified as a suicide risk. So our policy reviews what you should do.

The first one is a same sex staff member can accompany the patient to a multi stalled restroom, and they stand on the outside of the stall, why that patients going to the restroom.

I've done with this, this with patients, when they understand why we're doing it, I've not yet had a patient asked me, why do you have to do that I don't want you to do that.

But also for patients who don't want to go to the multi stalled restroom with a staff escort. We do have a ligature free bathroom it's up on the in the old building up on the behavioral health peds section.

We talk about it in the suicide awareness response training that a patient could go there as well. I encourage everybody that if you are taking a patient there before you let the patient in the bathroom, you look, you see, how does this bathroom look does it look like all the risk

factors are out of that restroom.

Would you like to have a discussion with Elizabeth and I offline. Absolutely, please do. If anybody wants to have discussions about your area specifically of how can the suicide awareness Council help you, what are the supports that you need what are the things

that you need. We are here, and we want your feedback, we want your help. We want you to reach out to us so that we can make sure that our patients are getting the best care possible.

I'm just going back up.

Thank you. When I now see that the BR standard for bathroom alone so thank you, Dr. Horn for clarity as well I, I missed that one.

I'm not always into my hip logos that people are using in text messages nowadays. So, our next learning collaborative will be on April 26 we will be doing it again at noon.

And this was my first time I've ever recorded one of these so I hope I did the recording right. If not, I'm going to have Langdon come and join us next time, so that we can make sure that we're getting these on the spider web so that people can watch them when

they need to. But that will be suicide in the United States warning signs and risk factors that are happening.

Again, I'm going to stay on a little bit. I appreciate you all joining us today. I hope you can get some good lunch into you if you already haven't had it.

Yes, and thank you very much Dr. Horn for understanding, and just letting people know we know this can be difficult and sensitive topic. That's why we're here to help and support you.

Thank you all for attending.

Thank you.