A 1-Year Review of a Nationally Led Intervention to Improve Suicide Prevention Screening at a Large Homeless Veterans Clinic
Background: Suicide is a national public health concern and veterans are a particularly vulnerable population. The Veterans Health Administration (VHA) Office of Mental Health and Suicide Prevention implemented a national, standardized process for suicide risk screening in October 2018, which was instituted at the West Los Angeles Veterans Affairs Medical Center Homeless Patient Aligned Care Team (HPACT) clinic.
Methods: This article examines the results of the screening initiative after implementation, describes difficulties faced in implementation, and suggests strategies that might be used to overcome those challenges.
Results: Over 1 fiscal year (October 1, 2018 to September 30, 2019) the HPACT clinic had 2932 unique veterans assigned to its care; 1876 (64%) received a primary screen of suicide risk, 523 (18%) were not screened, and 533 (18%) were exempt from screening by protocol. Of the 523 (18%) unscreened patients, 331 (11%) patients had no HPACT visit and 132 (5%) did not visit any VHA site during the period. There were 192 (7%) patients who visited but were not screened of which 19 (1%) declined screening.
Conclusions: Most missed screening opportunities were due to patients being lost to follow-up. There were 5 challenges identified for screening implementation, including health record factors, communication, clinician buy-in, system factors, and patient factors. Thus, 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 were all effective in increasing comfort with suicide assessment and screening rates.
Finally, while the percentage of patients who were considered missed opportunities (visited the HPACT clinic but were not screened) was relatively small at 6% of the total panel of patients, this number theoretically should be zero. Though this project was not designed to identify the specific causes for missed opportunities, future QI efforts may consider evaluating for other potential reasons. These may include differing process flows for various encounters (same-day care visits, scheduled primary care visit, RN-only visit), screening not activating at time of visit, time constraints, or other unseen reasons. Another important population is the 11% of patients who were otherwise eligible for screening but did not visit the HPACT clinic, and in some cases, no other VA location. There are a few explanatory reasons centered on the mobility of this population between health systems. However, this patient population also may be among the most vulnerable and at risk: 62% of veteran suicides in 2017 had not had a VA encounter that year.13 While there is no requirement that the veteran visit the HPACT clinic annually, future efforts may focus on increasing engagement through other means of outreach, including site visits and community care involvement, knowing the nature of the sporadic follow-up patterns in this patient population. Future work may also involve examining suicide rates by primary care clinic and triage patterns between interprofessional staff.
Limitations
Due to the limited sample size, findings cannot be generalized to all VA sites. The QI team used retrospective, administrative data. Additionally, since this is a primary care clinic focused on a specialized population, this result may not be generalizable to all primary care settings, other primary care populations, or even other homeless primary care clinics, though it may establish a benchmark when other clinics internally examine their data and processes.
Conclusions
Improving screening protocols can lead to identification of at-risk individuals who would not have otherwise been identified.16,17 As the US continues to grapple with mental health and suicide, efforts toward addressing this important issue among veterans remains a top priority.
Acknowledgments
Thank you to the VAGLAHS Center of Excellence in Primary Care Education faculty and trainees, the HPACT staff, and the VA Informatics and Computing Infrastructure (VINCI) for data support.
