A 1-Year Review of a Nationally Led Intervention to Improve Suicide Prevention Screening at a Large Homeless Veterans Clinic

During this process, the interprofessional team overseeing the suicide screening implementation efforts in the HPACT clinic met in-person biweekly beginning 1 month prior to the October 1, 2018 implementation. QI tools, including flowcharts and root cause analyses, were used to analyze feedback on efficient workflow and optimize staff responsibilities. A survey assessed staff comfort and familiarity using the suicide screening tools. Informal interviews were conducted with a representative from each stage of patient care to facilitate interprofessional participation and to troubleshoot any issues. Process flowcharts that clearly delineated staff roles based on current clinic workflow and the recommendations set forth by the new process were distributed at an initial staff meeting. The process flowchart was updated after staff feedback and distributed again along with a review of the C-SSRS and CSRE at an all-staff meeting in February 2019. The QI team continued to meet to formally evaluate their SMART Aims and to identify factors driving the success and failure of the implementation.

The VA Informatics and Computing Infrastructure (VINCI) provided project data after a formal request was submitted for this analysis. At the direction of the local QI team, the VINCI team provided aggregate patient counts derived from individual patient data in the VA Corporate Data Warehouse. The data analyzed are frequencies and proportions; no bivariate or multivariate statistics were performed.

Results

During the project year, the HPACT clinic had 2932 unique patients assigned to primary care. Of those veterans, 533 (18%) were exempt from screening by protocol. Of the remainder, staff screened 1876 (64%) of eligible veterans for suicide risk (Figure 2), which did not meet the SMART Aim of screening > 90% of eligible veterans. For the follow-up screens, using a QI dashboard designed for reviewing I9 and C-SSRS results, the QI team reviewed a convenience sample of 5 provider panels and identified 34 positive I9 screens. Twenty of those 34 patients (59%) received a C-SSRS within 24 hours of the positive I9, which did not meet the SMART Aim of ensuring > 90% of primary I9 screens had subsequent C-SSRS screening within 24 hours.

Of the veterans screened, 1,271 (43%) had their screening performed outside of the HPACT primary care team assigned, while 605 (21%) patients had their screening performed by an HPACT member. Most of the screening that occurred outside of the assigned primary care team occurred in other physical settings, including other VA facilities.

Of the 523 (18%) patients who were not screened, 331 (11%) patients had no visit to the HPACT clinic and 132 (5%) empaneled patients did not visit any VA site within the 1-year period. There were 192 (7%) patients who were not screened that had a visit to HPACT while 19 (1%) of those patients declined screening. A total of 184 (6%) patients were not screened and thus were considered true missed opportunities. This group of patients were eligible for screening but did not undergo screening in the HPACT clinic or any other VA setting despite visiting the VA.

The QI team created a fishbone diagram to identify opportunities to improve screening rates and patient care (Figure 3). Using the fishbone tool, the QI team identified 5 main categories limiting complete uptake of suicide risk assessment at the HPACT clinic: health record factors, communication, clinician buy-in, system factors, and patient factors. Among the most salient barriers to use of the screening tool, the EHR system needed to be refreshed after a positive screen to be reminded of the next step, requiring close communication during patient handoffs. Handoff was confusing as there was no dedicated process to communicate positive screen information. Clinicians were concerned that completing the process, especially the tertiary screen, would be time consuming and burdensome in an already busy clinic; some clinicians were uncomfortable discussing the topic of suicide as they did not feel they had the expertise to address a positive screen. In addition, some patients were reluctant to answer the screen honestly due to past hospitalizations or concerns about stigma.

Discussion

Though the QI project failed to meet the SMART Aim of ensuring > 90% of eligible patients received a primary screen for suicide risk and > 90% of positive primary I9 screens received subsequent screenings within 24 hours, the results highlight effective practices and barriers for implementation of wide-scale EHR-based interventions for suicide assessment. Most missed screening opportunities were due to patients being lost to follow-up over the duration of the project, which is a challenge faced in this patient population. A recent analysis of the national rollout of this screening program found that 95% of eligible veterans with a visit to the VA in the first year of the program received screening.¹⁴ In a post hoc analysis using the same eligibility criteria, the rate of screening for this project was 83%. Reflecting on the data from this national cohort compared with the HPACT clinic, this brings to light potential circumstances that may be unique to veterans experiencing homelessness compared with the general veteran population, for instance, the level of engagement may be lower among veterans experiencing homelessness, though this is beyond the scope of this article. Nonetheless, promoting interprofessional collaboration, visualizing effective process flows, establishing clear lines of communication and roles for involved staff, and opening avenues for continuous feedback and troubleshooting are all potentially effective interventions to improve suicide screening rates within the veteran population.

This HPACT clinic initiative aimed to determine how a new screening process would be implemented while identifying potential areas for improvement. Surprisingly, 43% of patients who were screened had their screening performed outside of the HPACT clinic, most often in the inpatient setting at other WLAVAMC clinics or other VA systems. It is possible that due to the nature of the patient population that the HPACT clinic serves with intensive service needs, these patients have wider geographic and clinical location use than most clinic populations due to the transient nature of patients with housing insecurity. What is encouraging, however, is that through this systemwide initiative, there is an impetus to screen veterans, regardless of who performs the screening. This is particularly meaningful given that rates of depression screening may be as low as 4% among PCPs.¹⁵ During implementation, the QI team learned that nearly 18% of the empaneled HPACT patients were exempt from screening. The exempt patients do not have an active clinical reminder for depression screens. Instead, these patients are receiving mental health surveillance and specialty treatment, during which continuous monitoring and assessment for suicidal ideation and risk of suicide are performed. Additionally, an EHR-based factor that also may limit appropriate follow-up and contribute to missed opportunities is that secondary and tertiary screens do not populate until the EHR was refreshed after positive primary screens, which introduces human error in a process that could be automated. Both RNs and PCPs may occasionally miss secondary and tertiary screens due to this issue, which continues to be a barrier. Given the high risk HPACT clinic population, the QI team encouraged staff members to frequently screen patients for suicidal ideation regardless of clinical reminders. A consideration for the future would be to identify optimal frequency for screening and to continue to validate assessment methods.