Markian Hawryluk
The Bulletin

The Henry Ford Health System set out to radically transform its mental health delivery system in 2001, asking its behavioral health staff to design a model for ideal depression care. As part of those discussions, the team created various measurable goals including one for reducing suicide among its patients.

As they debated what that goal should be, one of the team members asked a provocative question: Why shouldn’t it be zero?

That concept gave rise to an approach known as Zero Suicide, that is rapidly becoming the leading suicide prevention strategy for health systems. It’s a fundamental shift in thinking to consider that every suicide is potentially preventable and that getting to zero suicides is a realistic goal. Now a handful of public health organizations, including Deschutes County Health Services, are trying to take that same approach on a communitywide basis.

“When you see the number of some of the organizations that have done it, they’ve had some amazing statistics,” said David Visiko, suicide prevention coordinator for the county. “It’s one of those hot interventions that we’ve seen on a systemic level that’s working.”

A new approach

Suicide has historically been considered an unfortunate, but inevitable outcome for a certain percentage of individuals with mental illness. While most health care organizations have adopted various suicide prevention strategies, care is often disjointed, allowing patients to fall through the cracks. A provider may ask about and treat depression, but not take the extra step of asking whether a patient has considered suicide. Or when patients do express suicidal thoughts, often they are referred to a mental health provider, but no one follows up to make sure the patient was able to see that specialist.

Studies have shown that roughly half of individuals who died by suicide saw a primary care provider in the previous 90 days, and about a third had seen a mental health provider.

“If we get people into care, we ought to be able to save those people,” said Susan Keys, an associate professor at OSU-Cascades in Bend. “What do we need to do differently to keep people who come in for care from slipping through that safety net?”

The Zero Suicide approach expressly rejects the notion that some suicides are just inevitable, and implements a systemswide approach based on training, access to treatment and follow-up to avoid losing patients.

The Henry Ford model incorporated a number of proven interventions, including improving access to care through same-day evaluations by a psychiatrist and drop-in group visits, as well as protocols to remove lethal weapons from homes of patients at risk. They changed their screening tools to assume that every patient with a mental illness is at increased risk. The systemic approach was designed to ensure that patients at risk weren’t falling through the cracks and that if a suicide did occur, the health system would analyze what happened and learn from that event.

The effects of the new approach were dramatic. In less than a decade, the health system reduced its suicide rate by 80 percent, and by 2010, the system had not seen a single behavioral health patient die by suicide in more than two years.

“We have found that when you bundle best practices and don’t just pick one of them … you see a reduction in suicide rates,” said Dr. Jerry Reed, director of the Suicide Prevention Resource Center and an executive committee member for the National Action Alliance for Suicide Prevention.

The alliance is a public-private partnership created in 2010 by then Health and Human Service Secretary Kathleen Sebelius and Defense Secretary Robert Gates and charged with creating a national strategy for suicide prevention. The alliance built the Zero Suicide approach from the example at Henry Ford, creating a framework of seven elements that health care organizations need to incorporate for effective suicide prevention. Organizations can then choose which proven strategies to adopt in order to meet all seven elements.

Reed said there are many individual best practices for suicide prevention with solid evidence that they help. The group is now trying to gather the data to show that by bundling such strategies in a holistic approach, they can drive down suicide rates to dramatic lows.

“Each of the seven elements have evidence behind them,” he said. “What we are now building is the evidence for the bundle.”

The Zero Suicide approach has been designed for health care organizations, who have a set group of patients and providers, with the ability to implement the seven elements across the entire patient population and then to measure its impact. But increasingly, organizations such as county or state health departments have been interested in adopting a similar approach.

“Communities play an incredibly active role in suicide prevention, and Zero Suicide speaks to them because of its aspirational nature,” Reed said.

The alliance is preparing to release a white paper as soon as this month that will describe how community organizations can implement an integrated suicide prevention plan based on the Zero Suicide concept.

Community efforts

Several years ago, a community health needs assessment in Washington County, Oregon, found a particular need for suicide prevention.

“We really saw that suicide had a significant impact on our community, particularly among older white men and our veteran population,” said Meghan Crane, the county’s suicide prevention coordinator.

Public and mental health officials created a suicide prevention council with providers, community stakeholders and members of the community to tackle the problem. One of the council members had heard about the Zero Suicide approach for health systems and suggested the county adopt it as well.

The county was one of the first in the nation to take on that strategy, and Crane has been working with individual organizations to conduct trainings and to help those move toward Zero Suicide.

“In the past, it’s been about heroic efforts of individual clinicians saving people,” Crane said. “We need to put in a systemwide safety net that will save those people.”

Lifeworks Northwest, the contracted behavioral health provider for Washington County, has agreed to implement Zero Suicide in its operations, and the council has helped facilitate training of hundreds of providers and employees on suicide prevention strategies.

But Crane says it could take years before the program is fully in place and suicide rates drop significantly.

“Getting everybody through training and up to speed on a new policy, that alone takes that long,” she said. “It’s a multi-year process for organizations to get through.”

Local progress

Deschutes County is in the very early stages of adopting the Zero Suicide approach. Preliminary data for 2016 show 33 suicides for Deschutes County, seven in Crook County and three in Jefferson County.

Visiko stresses that while getting to zero is the aspirational goal, it’s not simply a matter of checking off items on a list and not expecting to see any more suicides in the county.

“It’s got to be a process that happens within an agency, depending on what their resources are, their time commitment and the leadership involved,” he said. “But let’s say we prevent five suicides instead of zero. Well, what if one of those five is someone you know? We’re just setting the bar really high.”

County officials held an informational meeting in February for providers and other organizations interested in the approach. Visiko is now working to convince several organizations within the community to take on the strategy. Youth Villages, a nonprofit serving children with emotional and behavioral needs, has signed on statewide and has a branch in Bend. St. Charles Health System is also embarked on implementing Zero Suicide within its behavior health unit, and may eventually expand that to the entire health care system.

“We chose to implement it first with the behavioral inpatient team, so that we can get a handle on what’s the appropriate way to train, what are the resources that we are going to need, so we can hopefully plan for that in the future,” said Molly Wells Darling, director of inpatient behavioral health services for the St. Charles Health System.

The training will include everyone in the organizations, including secretarial and support staff, giving them a set of tools and strategies to identify individuals at risk and to understand how to get them to the right person for help.

“Ultimately when you look at Zero Suicide, it’s a different approach in the mental health system,” Darling said. “We are really targeting zero suicides overall. That’s not just for our patients, that’s for anyone we come into contact with: co-workers or family members or friends. There is help out there, and suicide is absolutely preventable.”

The health system already screens all its inpatients for suicide risk and connects those identified with social workers that can connect them with additional resources. But under the Zero Suicide approach, the behavioral health team is using an expanded survey that doesn’t merely identify patients at risk, but stratifies their risk to determine what level of intervention is necessary.

St. Charles also has an initiative underway for youth who present to the emergency room with any suicide risk, bringing in Youth Villages to ensure that patient is not lost to follow-up care after discharge.

Last year, the Joint Commission, which accredits hospitals and other health care organizations, recently sent out a sentinel event alert advising hospitals they need to better identify and treat individuals at risk for suicide. That could further drive interest in the Zero Suicide framework.

Zero Suicide is also part of the national strategy for suicide prevention, and federal grants for suicide prevention are now requiring grantees to incorporate the strategy as a condition of funding. Oregon is redefining the role of its suicide prevention coordinator and will even rename the position as the Zero Suicide coordinator.

“What really excites me about it is it makes it look possible,” said Donna Noonan, Oregon’s suicide prevention coordinator. Noonan has officially retired from the post, but is serving as a consultant to the state until a new coordinator can be hired.

Suicide is the eighth leading cause of death in Oregon, and among youth, it’s the second. Oregon, like most Western states, has suicide rates above the national level.

“The reality is, we’re more likely to come in contact with somebody who is suicidal than somebody having a heart attack,” she said.

Keys, who is part of an effort to collect Zero Suicide strategies from across Oregon into a toolkit for interested providers, says stakeholders need to walk a fine line when talking about the ability to get to zero.

“We have to be careful because we don’t want to alienate people who lost somebody by suicide and create feelings of guilt,” she said. “Individuals do the best they can, but the challenges are within the system.”

Similar concerns apply to providers who may feel the pressure of getting to zero is too great. The goal is clearly motivational for many, but others may resist or feel it’s not really possible.

“We’re not going to take ourselves to task if we have a suicide, but we are going to move toward something that we would aspire to,” Keys said. “And I think buying into that is easier than making themselves feel guilty if they don’t prevent every one.”

— Reporter: 541-633-2162,