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Laura Leone, MSSW, LMSWUpper Manhattan Regional Director of Psychosocial Services
The Institute for Family Health
Mission Provide care to those who need it most
Use the family practice model of care
Train students and health professionals
Promote diversity in the healthcare workforce
Participate in health services research and policy development
Staff and Budget Over 900 staff members (Manhattan, Bronx and Upstate)
A budget of approximately 92 million dollars
450,000 visits yearly
Equal numbers of behavioral health staff
Medical, dental, pharmacy and mental health programs Special programs/population Educational programs Research Health Information Technology
6 Manhattan Centers
5 Bronx Centers
6 Mid-Hudson Centers
2 Free Clinics
8 Care for the Homeless
sites
5 Ryan White HIV/AIDS
programs
7 Mental Health Centers
• Manhattan and the
Bronx in New York City
• Mid Hudson Valley
• Diverse economic and social backgrounds
• Latino, African-American, Caribbean-American, or recent immigrants
Roughly 85,000 patients make about 400,000 visits per year
Research on patients who touched primary care and had completed suicide
Several patients who completed suicide in 2010
Desire to train family practice residents
Organizational interest in addressing public health issues
Organizational interest in using technology to advance public and patient health
Mandatory training for ALL agency staff
Provided free for our staff through community training initiatives
To date almost 1,000 trained
ASIST – “Applied Suicide Intervention Skills Training”◦ 16 hour suicide first aid intervention training for all clinical
staff 2 day intensive training◦ Improve comfort, knowledge and skill level of staff to
identify and address patients at risk◦ Teach professional mental health staff to provide suicide
first aid interventions◦ Role play heavy
safeTALK – “Suicide Alertness for Everyone”◦ 3 hour suicide alertness training for all non-clinical staff
including front desk staff, administration, nursing, facilities◦ Teach staff how to move beyond tendency to miss, dismiss
or avoid suicide risk signs◦ Apply “TALK” steps to connect persons with thoughts of
suicide to first aid resources
Columbia Suicide Severity Rating Scale Means Restriction Counseling Relapse Prevention Plans Safety Plans AMSR – “Assessing and Managing Suicide Risk”◦ 8 hour suicide core competencies for behavioral health
professionals ◦ five of the most common dilemmas faced by providers
and the best practices for addressing them. Teaching and skill-building methods include: Video demonstrations Group discussion Paired practice Documentation practice Reflection Expert teaching
Electronic health record implementation in 2002
EPIC electronic health record system
Decided to use technology to help in identification and prevention of suicide in primary care patients throughout system
12
Collaborative Documentation
An ongoing challenge……
Address suicide in all sites, services and programs
Realized completed suicides were happening in primary care centers
Needed different workflows and tools for different providers
Multiple areas in chart
Reminder to providers
Allows quick access to needed tools or resources
Can be “hard stop”
Ability to report on providers who “ ignore” decision supports
Decision Support
BPA for annual PHQ-2
PHQ-9 BPA
Used consistently throughout health centers
Speak the same language
Attention to question 9
Graphing Results
“Blows” into all encounters
Readily seen by providers of all disciplines
Able to be reported on (number of patients)
Problem List Documentation
My Safety Plan document ◦ Allows safety plan information to be available to all
providers during all visits for review and/or modification
◦ Patients can access the document via patient portal for reference
◦ Community providers can see patients at risk through physician portals
◦ Provided in print to patients as part of after visit summary
◦ Signed by patient and provider
Modeled after Stanley and Brown Safety Plan Template
Includes:
Identification of triggers
Warning signs of increased symptoms
Management techniques or calming activities
Contact information for supportive persons
Plan to get emergency help if needed
Safety Plan
Columbia Suicide Severity Rating Scale Assessments
Notes:1. Negative on PHQ-2 is defined as a score of 0; Positive
on PHQ-2 is defined as a score of 1-2.2. Negative Response to PHQ-9, Question 9 is defined as a
score of 0; Positive Response to PHQ9, Question 9 is defined as a score of 1-3.
3. Negative on C-SSRS Screen is defined as a response of “No” on Questions 2 and 6; Positive on C-SSRS Screen is defined as a response of “Yes” on Question 2 or 6
4. Active or File to History/Resolved is determined in accordance with guidelines included in Problem List Entry Guidance
Response Pathway Assessment:
Response Pathway Resolution:
Response Pathway Maintenance:
Response Pathway Initiation:
Identification Pathways:
Care Events:
Any Point in Primary Care or Behavioral
Health Care
PHQ-2
Identification of Risk , Multiple Risk Factors or Other Non-Structured Identification of Risk
negative screen1
positive screen1
Add suicide related entry to the problem list AND Complete Safety Plan
Complete C-SSRS Lifetime/Recent Scale AND Risk Assessment
Complete C-SSRS Since Last Visit Scale AND Update/Review Risk Assessment AND Safety Plan at
each visit
Depression Screening in Primary Care
Depression Screening Behavioral Health Care
or Community Programs
Ongoing Depression Care in Primary Care or
Behavioral Health Care
Update suicide related entry on the problem list as indicated
Filed to history/
resolved4
Update suicide related entry on the problem list as indicated
Filed to history/
resolved4
negative Q92
Managing Suicidality: Clinical Pathways in Primary and Behavioral Health Care
!
!
!
> C-SSRS Screenpositive Q92
>
negative screen3
positive screen3
Active4
Active4
!
PHQ-9
!
A patient portal is a healthcare related online application that allows patients to interact with their healthcare providers.
What is a Patient Portal?
36
Why am I taking
this medication?
37
My Goals and Plans
You have a diagnosis of DEPRESSION
Here are your personal treatment goals:
Call your friend Ana on Tuesday at 7pm
MyChart Questionnaires
Physician/Organization portal as link to community
Over150 organizations and specialty providers on “Institute Link”
Foster care, mental health residences, DD programs
Pharmacy providers
Seamless care system
Expedited services
By-pass admissions
Decreased admissions
Overview of Content in Medical Record
Operational Reporting Populations
New to behavioral health providers
Operational Reporting Key Parameters
PHQ-9 Reports
Depression Registry
Percentage of patients with Suicide Related Entry on the problem list that have a completed:◦ Safety Plan
◦ C-SSRS Lifetime/Recent scale
95% 92%
0
100
200
300
400
500
600
Safety Plan C-SSRS Assessment
% of Total Complete
Exception
Complete
Review of all patients who attempt suicide and die by suicide – analysis
Review of all unexplained deceased patients
Hard stop for patients who are considered high risk
Participation in local, state and national initiatives
Learning to look to system to “solve problems”
Training, training and more training
Confidentiality and InstituteLink – state confidentiality concerns
Continued “buy in” from primary care providers
Thank You!
Laura Leone, MSSW, LMSW
Regional Director of Psychosocial Services
The Institute for Family Health
