A top expert urged Tompkins County healthcare leaders on August 9 to pursue implementation of the Zero Suicide Model, a framework designed to prevent suicide deaths by closing gaps in the care provided by healthcare systems.
Brian Ahmedani, suicide prevention expert at the Henry Ford Health System
Brian Ahmedani, director of the Center for Health Policy & Health Services Research at the Henry Ford Health System, said Zero Suicide has proved to be highly effective in Henry Ford’s pioneering work on the model over the past two decades. During a period between 2008 and 2010, he said, not a single Henry Ford behavioral health patient died by suicide.
Citing the continuing rise in the U.S. suicide rate in the past 20 years, Ahmedani said research now shows that healthcare systems can play an important role in reversing that trend..
“We need to do something about this, and the time is now,” he said. “So your charge is to map out a perfect system of care, develop processes and policies that align with that perfect system of care, and figure out who is going do each part of that system of care.”
Ahmedani made his remarks in a presentation to the Tompkins County Zero Suicide Steering Committee, a group of healthcare leaders formed in 2022 to work on implementing the model within and across healthcare systems serving the community. The presentation was sponsored by The Sophie Fund.
Ahmedani explained that the Zero Suicide model for healthcare as well as behavioral health settings entails patient screening, risk assessment, and care coordination.
It starts with systematic screening of all patients using evidence-based tools to determine if they have any suicide risk. If a patient screens positive, then a risk assessment is conducted to determine the onward care that is aligned with their level of risk. Zero Suicide calls for care coordination to avoid system gaps, and for the use of evidence-based treatments for suicidality such as Cognitive Behavioral Therapy.
Ahmedani said that the model calls for the provider and an at-risk patient together to develop a safety plan, a quick guide to help in a crisis that includes their personal warning signs, coping strategies, emergency contacts, and reminders of how to stay safe away from lethal means. Just the safety plan along with a follow-up caring contact message with a patient reduces suicide risk by 20 percent, he said.
“When somebody has suicidal ideation, it’s sort of like having paralysis of your brain, your body shuts down and it can only think of this escape pathway. So if you have a rehearsed plan, they know what they can do instead. If they don’t have a plan, that’s when they continue to get stuck in this this fixation when this intense wave of wanting to hurt yourself comes over your brain and takes over,” he said.
Explaining Zero Suicide’s inclusion of healthcare settings, Ahmedani noted that until 2012 conventional wisdom felt that suicide prevention was a mission left to the behavioral health field.
But he said that research indicates that more than 83 percent of people who died by suicide had made some type of healthcare visit in the weeks and months prior to their death; 92 percent of people making a suicide attempt had seen a healthcare provider very recently. Moreover, he added, studies now show that more than half of the people who die by suicide had no mental health diagnosis.
“That means they’ve never received psychotherapy, they’ve never come in for a suicide attempt in the past, there is no evidence of mental health diagnosis in their entire clinical history,” Ahmedani said.
“What that means is that we need different approaches for suicide prevention. We can’t just rely on waiting for someone to get a mental health diagnosis before we think about suicide prevention. Most people are connecting with healthcare systems before they’re dying. They’re right in front of us.”
Ahmedani said that primary care practices are an important setting for identifying people at risk who may never have sought mental health treatment.
“Most people are actually going to primary care before they’re dying by suicide. If we don’t do anything in primary care, we won’t be able to reach the vast majority of people who are right in front of us before they’re dying by suicide.”
Ahmedani said that behavioral health settings continue to be critical for preventing suicide, because patients with a mental health diagnosis are already known to be at an elevated risk. “But even if we provided perfect care in behavioral health, we could only reach about one third of the people who are dying by suicide,” he said.
Another argument for all healthcare settings also playing a role, Ahmedani said, is a realization that suicidality is not a symptom of a disease like depression but is actually its own disease that needs to be identified and treated as a comorbid condition.
“We really need to think more broadly than that it’s just some symptom of depression or symptom of substance use or symptom of something else, and that if we treat that thing then the suicide risk will go away. We actually have to treat those things concurrently. Both things need to be treated,” he said.
Ahmedani said that unlike longstanding strides to prevent cardiovascular disease, most of the effective interventions outlined in the Zero Suicide Model have only been developed by Henry Ford and others over the past two decades.
“The interventions really haven’t penetrated healthcare systems in the way that other disease treatments have,” he said. “But we have an opportunity to do that now. So I’m really encouraging us to think about how we can take advantage of it,” he said.
“This program is set up perfectly to structure within a healthcare system using pragmatic approaches and interventions that fit within healthcare so they don’t overburden the resources and staffing and all the costs. It is designed to work effectively in your program.”
Ahmedani stressed the importance of creating a healthcare system team to lead implementation of Zero Suicide, as they did in pioneering the model at Henry Ford.
“Our major recommendation is that you start and launch these services with a team of people that can represent the different perspectives in your healthcare system,” he said. Henry Ford’s team included system leadership, clinicians from different levels, and patients “so that we could really design a system of care that works for everybody,” he said.
Creating system teamwork to prevent suicide deaths removes a burden of responsibility from “the individual heroic clinician who works 24 hours a day, seven days a week trying to stay up and do all these things,” he said. “If we work as a team, we can reduce burnout, we can be more effective, and we can deliver services that end up leading downstream to a better result in preventing suicide.”
Ahmedani said that after implementing Zero Suicide’s quality care process improvements, Henry Ford saw a 75-80 percent reduction in suicide deaths among behavioral health patients within the first year. He said that reduction would then be sustained for more than 22 years even as the U.S. and Michigan suicide rates continued to climb; during an 18-month period from 2008-2010, no behavioral health patients died by suicide.
“Without doing all these things, people fall through the cracks. People aren’t identified, they see multiple providers most of the time, they interact with our healthcare system in lots of different ways, and we don’t figure out who they are. If we do each of those processes, people don’t fall through the cracks,” he said.
“We’ve got a lot of data that show that this program works not only at Henry Ford but it works at a lot of different health care systems. The goal of Zero Suicide is that, instead of thinking that suicide is inevitable like we used to, we’re now thinking suicides are preventable.”
To the surprise of many, Ahmedani said, Henry Ford increased its behavioral health revenue eight-fold after implementing Zero Suicide by reformatting and restructuring the way that it provides care.
He said that medical practices utilizing collaborative care models are able to bill insurance for suicide prevention procedures like screening, risk assessment, and care coordination. He said Blue Cross in Michigan is leading a partnership with healthcare incentivizing or paying for suicide prevention procedures.
Ahmedani said about 50,000 people die by suicide in the United States each year but that the scope of the problem is even bigger. He said 2 million people in the U.S. make a suicide attempt every year, and 15 million are thinking about suicide at some point in the year.
“So we’re talking about somewhere between 4-5 percent of the U.S. general population who are affected by suicide during a year. That’s a lot of people,” he said.
He said that suicide is the only one of the 15 leading causes of death in the United States whose annual rate has been increasing. The annual rate increased 25-30 percent over the past two decades, he said.
Ahmedani said that a significant step forward occurred with the release of the 2012 National Strategy for Suicide Prevention, which drew on Henry Ford’s work and for the first time declared that suicide prevention should be a core component of healthcare services and not only behavioral health.
Afterwards, The Joint Commission, a leading healthcare accrediting body, issued recommendations for preventing suicide in healthcare settings and requirements for using the latest processes and intervention tools in behavioral health settings.
Ahmedani noted that some people in healthcare get “twitchy” about the seemingly unrealistic notion of aiming for zero suicide deaths. “The long-term aspirational goal is to prevent every suicide, but the operational goal is to implement a system of care that focuses on error reduction,” he explained.
He noted that “designing for zero” is a practice seen in many areas, such as surgical operating theaters, airline travel, automotive manufacturing, and nuclear power plants. Setting a goal of zero suicides maintains a focus on continuous quality improvement, he said, reducing the opportunity for complacency. “If we strive for any other number, then we aren’t moving towards the ultimate goal,” he said.
Ahmedani serves as chair of Michigan Governor Gretchen Whitmer’s Suicide Prevention Commission. Besides his work on Zero Suicide at Henry Ford, he is a principal investigator for a number of current clinical trials and studies around suicide and healthcare; one of them is evaluating the implementation of the Zero Suicide Model in various settings of six healthcare systems in five states serving 10 million patients a year.
The creation of the Steering Committee was a response to Goal 2 of the Tompkins County Suicide Prevention Coalition’s Three-Year Strategic Plan 2022-2025 adopted in February 2022. One of Goal 2’s objectives is to “form a Zero Suicide Work Group comprised of leading health and mental health providers to share ideas, experiences, and challenges, and lead collaborative, sustainable efforts to implement the Zero Suicide Model throughout Tompkins County.”