Safety Planning Intervention Telehealth Service Model in Emergency Departments

Study Overview
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Brief Summary
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The purpose of this study is to evaluate the effectiveness and implementation of a suicide prevention strategy delivered via telehealth in Emergency Departments. We will compare implementation of the Safety Planning Intervention plus follow-up calls (SPI+) delivered by Emergency Department (ED) staff to SPI+ delivered via ED referral to an off-site Suicide Prevention Consultation Center (SPCC).

Detailed Description
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Individuals at high risk for suicide often present to acute care settings, such as emergency departments (EDs), and then typically are hospitalized or referred for outpatient mental health treatment. Patients are at increased risk of suicide attempts and suicide following an ED visit and nearly half do not attend outpatient treatment. Brief, evidence-based clinical interventions, such as the Safety Planning Intervention with post-discharge telephone follow-up (SPI+), can reduce suicide risk, decrease hospitalizations, and increase engagement in outpatient services for suicidal patients discharged from the ED. Leveraging insights from implementation science and collaborative care, we propose a model in which ED staff will connect patients at risk for suicide to ED-credentialed mental health clinicians who are located external to the ED. These off-site clinicians will provide SPI+ via telehealth for ED patients prior to discharge and provide follow-up services after ED discharge as part of an innovative Suicide Prevention Consultation Center (SPCC). All participating EDs will begin in the Enhanced Usual Care phase, in which ED staff will deliver SPI+ to suicidal patients. EDs will then be randomized in pairs to begin referral to the SPCC in 3 month intervals. We will also conduct a cost evaluation to help determine scalability and sustainability.

Official Title
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A Safety Planning Intervention and Follow-up Telehealth Service Model for Suicidal Individuals in Emergency Department Settings

Conditions
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Suicide, Suicidal Ideation

Intervention / Treatment
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* Behavioral: SPI+ Delivered by ED Staff
* Behavioral: SPI+ Delivered by SPCC Clinicians


Participation Criteria
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Eligibility Criteria
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Aim 1/Aim 3: Inclusion Criteria: ED visit at one of our participating sites for a suicide-related event or determined to be at risk for suicide per the Electronic Health Record (EHR) and ED clinical staff 18 years of age or older Not admitted to an inpatient hospital following the index ED visit as documented in the EHR Exclusion Criteria: - Inpatient admission following the index ED visit per the EHR Aim 2: Inclusion Criteria: ED clinician or leader at one of our participating sites, or ED patient who was referred to the SPCC 18 years of age or older Able to communicate in English Willing to give informed consent Exclusion Criteria: Patients who are at imminent risk of suicide or acutely psychotic at the time of the interview, requiring emergency services and/or precluding ability to provide informed consent Patients without a phone for contact

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: Stepped-wedge cluster-randomized controlled design
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Enhanced Usual Care<br>ED staff deliver SPI+ (Safety Planning Intervention plus 2 or more post-discharge telephone calls) to suicidal patients who are not admitted to an inpatient unit. | Behavioral: SPI+ Delivered by ED Staff<br>* ED staff will deliver SPI+ (Safety Planning Intervention plus follow-up phone calls) to patients at risk for suicide in the ED who are not admitted to an inpatient unit.<br>|
| Experimental: Suicide Prevention Consultation Center<br>ED staff refer suicidal patients not admitted to an inpatient unit to the off-site Suicide Prevention Consultation Center (SPCC). SPCC clinicians will deliver SPI+ (Safety Planning Intervention plus 2 or more post-discharge telephone calls) to patients via telehealth. | Behavioral: SPI+ Delivered by SPCC Clinicians<br>* The Suicide Prevention Consultation Center (SPCC) will be located external to the Emergency Department (ED). ED staff will be able to refer patients at risk for suicide to the SPCC. Licensed and credentialed mental health clinicians will deliver SPI+ (Safety Planning Intervention plus follow-up phone calls) via telehealth to patients at risk for suicide in the ED who are not admitted to an inpatient unit.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Suicide Behavior Composite | Number of patients who had a documented suicide attempt or death by suicide | 6 months after index ED visit | 
| Outpatient Treatment Engagement - Count | Number of behavioral healthcare visits following discharge from index ED visit | 6 months after index ED visit | 
| Outpatient Treatment Engagement - Type | Types of behavioral healthcare visits following discharge from index ED visit | 6 months after index ED visit | 
| Safety Planning Intervention Scoring Algorithm (SPISA) | Fidelity of written safety plans post-discharge from index ED visit | At index ED visit | 
| Fidelity of Follow-up Calls | Number of patients who had 2 or more follow-up calls post-discharge from index ED visit | 1 month after index ED visit | 
| Reach/Penetration of Safety Plans | Proportion of patients with a completed safety plan documented in the medical record out of all patients identified as at risk for suicide by the ED staff | At index ED visit | 
| Reach/Penetration of Follow-up Calls | Proportion of patients who receive 2 or more telephone follow-up attempts out of all patients who received a safety plan | 1 month after index ED visit | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Suicide-related ED Visits and Psychiatric Hospitalizations | Number of ED visits and/or inpatient psychiatric admissions for suicidal ideation/behavior | 6 months after index ED visit | 
| Suicide Attempts | Number of patients who had a documented suicide attempt | 6 months after index ED visit | 
| Adoption | Proportion of clinicians with eligible patients who refer the patient to the SPCC | At index ED visit | 
| Utilization of Screening of Suicide Risk Among ED Patients | Proportion of ED patients who received the Columbia Suicide Severity Rating Scale or equivalent evidence-based measure of suicide risk during index ED visit | At index ED visit | 
| Index ED Visit Inpatient Admission Disposition | Proportion of patients admitted for inpatient hospitalization out of all patients identified as at risk for suicide | At index ED visit | 
| Feasibility of SPCC | Will be assessed through semi-structured qualitative interviews with a randomly selected sample of clinicians, leaders, and patients, as well as by using the Feasibility of Intervention Measure (FIM) | 9-12 months after ED crosses over to SPCC condition | 
| Acceptability of SPCC | Will be assessed through semi-structured qualitative interviews with a randomly selected sample of clinicians, leaders, and patients, as well as by using the Acceptability of Intervention Measure (AIM) | 9-12 months after ED crosses over to SPCC condition | 
| Cost to Emergency Department of SPCC | We will assess average personnel and non-personnel costs to Emergency Department practices of delivering SPCC and EUC strategies, using Time-Driven Activity-Based Costing | After ED crosses over to SPCC condition (2.25 - 3 year range, average of 2.625 years) | 
| Cost to Emergency Department of EUC | We will assess average personnel and non-personnel costs to Emergency Department practices of delivering EUC strategies, using Time-Driven Activity-Based Costing | Before ED crosses over to SPC condition (1 - 1.75 year range, average of 1.375 years) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Safety Planning, Emergency Department, Risk Assessment, Follow-up Contact, Implementation Strategies, Telehealth