Zero Suicide: Best Practices for Primary Care

Virna Little, Chief Operating Officer & Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers, trumpets the importance of preventing suicide in primary care.

Research shows that about 84 percent of people who die by suicide, and 92 percent of those who attempt suicide, had a healthcare visit within a year of their acts, Little said in her presentation, “Best Practices for Primary Care,”at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

Little also cited recent research indicating that people who died by suicide had suddenly resurfaced in primary care and became active on their healthcare portals within a month of their deaths.

Little spoke of her experience in conducting Zero Suicide trainings for 3,000 primary care providers in 27 states. She found that while 95 percent of the providers considered suicide prevention as part of their role, many of them were not trained either in their current positions or in their previous education. She found that many felt they did not have the knowledge or time to assess and intervene with an individual at risk of suicide.

She added that more than half of the behavioral health providers in these primary care settings did not feel comfortable or confident to care for someone at risk for suicide. She found that some people in her trainings were not familiar with the standard Patient Health Questionnaire that includes a key screening question about self-harm (PHQ-9).

Part 5 in a Series about the Zero Suicide Model for Healthcare

Little reported that many providers who had received traditional suicide prevention training did not feel it was helpful due to the trainers’ lack of understanding of how primary care practices operate.

“There are all kinds of places in primary care where people can fall through the cracks,” she said. “What I wanted to do was bring the idea of Zero Suicide and suicide safer care right to the front line, to make sure that we were doing something that would change what was happening in the primary care visit for people that were at risk for suicide.”

In her experience engaging primary care providers, Little said, they could easily identify their population of patients who suffered from diabetes but were usually silent when asked about how many of their patients were at risk for suicide.

Little felt that pediatric providers don’t really understand the extent of the problem of youth suicide. She cited data from the 2019 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention indicating that 8.9 percent of high school students in the survey had attempted suicide in the past year, and 18.8 percent had seriously considered taking their own lives.

In her training, Little urges primary care providers to adopt the seven core elements of the Zero Suicide Model, to bring a systemic approach to suicide care into their practices. Little stressed the importance of engaging everyone in a primary care practice, whether physicians and nurses or front desk and billing staff, in the process of suicide care.

“I often give an example of a practice where somebody cancelled three appointments within a very close time frame, and died by suicide,” Little said. “Nobody who answered the phone knew that she was at risk for suicide to do anything different. There was no process in place to catch that.”

Little’s training takes providers through the Zero Suicide protocols: effective screening procedures, speaking directly with patients identified as at risk, safety plans for patients, referrals to behavioral health specialists, and follow-up caring contacts.

She advises primary care providers to include suicidality on their patient problem lists, which provide immediately accessible structured data on their patients’ most important illnesses, diseases, injuries, or other health issues. “Imagine telling your primary care provider something really important, and then the next time you came in nobody even remembered,” she said.

Little said she also speaks with primary care providers about creating “pathways” of care for suicidal patients within their practice, and thinking about appropriate levels of  care so that suicidal patients are not automatically dispatched to hospital emergency departments.

“For example, everybody that comes in with chest pains, we would probably do an EKG, not everybody would go to the emergency room,” she said. “Not everybody who is asthmatic goes to the emergency room. So, one of our jobs in primary care is to make sure that people get the appropriate level of care.”

Little said that she found suicide care became more relatable when the primary care providers understood how discussing a patient’s suicidal thoughts with them and making referrals was little different than the usual workflows they use for patients with other issues like high blood pressure or asthma.

“Making those comparisons for primary care providers was incredibly helpful because it really helped them say, ‘Wait a minute you know what? I actually do this.’ I would remind them that, yeah, we shift gears all day long in primary care. It would be a beautiful day in primary care if somebody came in and they just had one thing going on and it was the actual thing that was the most urgent. If you’re going to engage primary care providers in this work, you have to speak primary care.”

She also said it was useful to provide primary care practices with role modeling for visits by individuals at risk for suicide, and to share storage statements with them that can be used to speak with such patients. She takes primary care providers through a role play of getting an at-risk individual to put the National Suicide Prevention Lifeline number in their phone contacts, or to access, a website that shares stories of how people have coped with and survived painful emotions.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.