Improving Care Transitions for Patients With Suicide Risk

Laura M. Cascella, MA, CPHRM

Mental health is a persistent and growing public health concern, and the number of Americans who commit suicide has steadily increased over the last two decades.¹ In 2022, an estimated 13.2 million adults had serious thoughts of suicide, 3.8 million adults made a suicide plan, and 1.6 million adults attempted suicide.² These statistics speak to the serious nature of the mental health crisis and the need for better interventions for people who have suicidal ideation.

Healthcare providers in various settings might be in an optimal position to intervene, as research shows that people who die by suicide more frequently utilize health services than the general population. In fact, more than half of people who die by suicide have a healthcare visit within 30 days of their deaths.³

Many healthcare organizations have implemented policies and initiatives to better identify patients who have suicidal ideation and provide or connect them with appropriate treatment. However, care transitions among healthcare providers and within and between organizations remain an area of particular concern and vulnerability for patients with suicide risk.

Implementing strategies and evidence-based practices at both organizational and patient care levels can improve care transitions and demonstrate a commitment to high-quality, patient-centered care that prioritizes suicide prevention. These efforts also can help eliminate ambiguity in processes, reinforce standardization, prevent communication failures, and reduce liability exposure.

Organizational Level

Improving care transitions for patients with suicide risk starts at the organizational level. As with any safety initiative, leadership buy-in and support are critical for creating lasting improvements. The following strategies can help support organizational progress and change:

• Identify the types of care transitions occurring throughout your organization that may involve patients with suicide risk (e.g., emergency department to outpatient, emergency department to inpatient, inpatient to outpatient, primary care to specialist, etc.). Although some elements of transitions will likely be similar, others might be unique to the type of situation and may have distinct implications for these at-risk patients.
• For each type of transition, document the individuals who are involved, the steps that occur, the information that is shared (and how it’s shared), and when the transition occurs. Mapping the process can help teams think about the effectiveness of safety protocols as well as potential deficiencies.
• Develop policies that specifically support care transitions for patients with suicide risk. Policies should delineate the required steps during each type of transition, appropriate staff involvement and outreach to external supports, considerations related to information sharing, follow-up requirements (e.g., with patients and consulting providers), and any available resources that may prove helpful.
• Make sure organizational policies address standards and expectations for documenting care transitions, and reinforce the need for healthcare providers to document all pertinent steps in patients’ health records. Periodically audit documentation to ensure compliance with policies.
• Foster collaboration with other healthcare organizations and community resources to improve care transitions for patients with suicide risk, better support these patients during vulnerable periods, and ensure access to suitable care.
• Formalize collaborative agreements, memoranda of understanding/agreement, procedures, and expectations related to patient triage, rapid referrals, and follow-up care. Determine key tasks, timeframes, and responsibilities for each provider involved in the patient’s care.
• Devise strategies to close the communication loop among providers within and between various healthcare settings to prevent patients from slipping through the cracks during care transitions.
• Educate providers and staff members about the risks associated with care transitions for patients who have suicide risk, the importance of thorough and successful transitions, and organizational policies related to care transitions for this vulnerable population. Provide education appropriate to each team member’s roles and responsibilities (both at hire and periodically thereafter).
• Identify methods to collect data and monitor the effectiveness of care transitions for patients who have suicide risk. Determine best practices for sharing data with providers/staff, identifying lessons learned, and devising quality improvement efforts.
• Ensure your organization promotes a just culture in which errors or process gaps are viewed as learning opportunities rather than individual shortcomings. Providers and staff members should feel encouraged and empowered to raise concerns and offer solutions.⁴

Patient Care Level

While an organization’s overall strategic approach to care transitions for patients with suicide risk can help establish expectations and reinforce consistency, interventions at the patient care level also can have a significant impact. The following strategies can help healthcare teams address gaps, strengthen safety precautions, and better support patients:

• Learn about and raise awareness of patient-centered, trauma-informed approaches to care. Use these techniques when communicating with patients to help build trust and potentially improve outcomes.
• Include families, caregivers, and significant others in patients’ care (with patient permission as required by state and federal privacy laws) to help facilitate care transitions, support patients during potentially difficult changes, and encourage adherence to follow-up care recommendations.
• Prior to care transitions, provide patient counseling and educational interventions to help reduce upheaval, address specific needs, and build a safety net. Examples include brief patient education, verbal and written information about crisis centers and hotlines, and lethal means counseling.
• Engage patients in the process of developing safety plans that help them recognize their personal warning signs, develop coping strategies, improve their environmental safety, and identify important contacts that can help them through crisis periods.
• Consider using trained peer specialists who can draw on their own lived experiences with suicide and/or mental health struggles to support patients as they transition through levels of care and help them navigate the system.
• When possible, use warm handoffs to ensure direct contact between patients and subsequent providers. This method can help alleviate patients’ fears and anxiety associated with care transitions and unknown circumstances.
• Make sure patients have all relevant details about follow-up care, including dates, times, locations, and contact information.
• Implement a process for patient outreach during care transitions, such as the use of caring contacts — i.e., brief communications to help engage patients in continued care and foster an ongoing sense of support. Caring contacts may take the form of postcards, text messages, calls, letters, and so on.⁵

In Summary

Care transitions, although common in healthcare, have been linked to adverse events. For patients with suicide risk, care transitions represent a particularly perilous time. Thus, it’s imperative for healthcare organizations and providers “to ‘narrow the gap’ between care environments as much as possible. . .”⁶ Developing policies and implementing strategies at both the organizational and patient care levels can help ensure patients receive the critical care and attention they need as they move along the continuum of care.

Endnotes

¹ Centers for Disease Control and Prevention. (2024, April 25). Suicide prevention: Facts about suicide. Retrieved from www.cdc.gov/suicide/facts/index.html; American Foundation for Suicide Prevention. (n.d.). Suicide statistics. Retrieved from https://afsp.org/suicide-statistics/

² Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health. Retrieved from www.samhsa.gov/data/report/2022-nsduh-annual-national-report

³ Ahmedani, B. K., Westphal, J., Autio, K., Elsiss, F., Peterson, E. L., Beck, A., . . . Simon, G. E. (2019). Variation in patterns of health care before suicide: A population case-control study. Preventive Medicine, 127, 105796. doi: https://doi.org/10.1016/j.ypmed.2019.105796

⁴ Zero Suicide. (n.d.). Zero suicide toolkit: Transition best practices. Retrieved from https://zerosuicide.edc.org/toolkit/transition; National Action Alliance for Suicide Prevention. (2019). Best practices in care transitions for individuals with suicide risk: Inpatient care to outpatient care. Retrieved from https://theactionalliance.org/resource/best-practices-care-transitions-individuals-suicide-risk-inpatient-care-outpatient-care; National Action Alliance for Suicide Prevention. (2021). Care transitions: Outpatient health care self-assessment. Retrieved from https://theactionalliance.org/resource/care-transitions-outpatient-health-care-self-assessment; Utah Zero Suicide Learning Collaborative, & Utah Department of Human Services Substance Abuse and Mental Health. (2018). Safe care transitions for suicide prevention. Retrieved from https://zerosuicide.edc.org/sites/default/files/Safe%20Care%20Transitions%20DSAMH%202018%20%281%29.pdf; Suicide Prevention Resource Center. (2015). Caring for adult patients with suicide risk: A consensus guide for emergency departments. Retrieved from https://sprc.org/wp-content/uploads/2022/11/EDGuide_full-1.pdf

⁵ Ibid.

⁶ Zero Suicide, Zero suicide toolkit: Transition best practices.

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