Joint Commission guidance for managing suicide ideation

On February 24, 2016, The Joint Commission (TJC) issued a Sentinel Event Alert with guidance for detecting and treating suicide ideation applicable to all health care settings. Because providers often fail to detect suicidal thoughts in their patients at the point of care, with some of these patients eventually succumbing to their suicidal ideations, TJC has developed step-by-step guidance to assist providers in implementing comprehensive patient care plans covering suicide risk assessment, screening and detection, safety measures, treatment, discharge, follow-up care, and education and training.

Joint Commission accredited organizations should implement TJC's 4-step plan when designing or redesigning patient care plans and resources for patients, providers, and staff. Joint Commission accredited organizations are encouraged to comply with TJC's below recommendations to reduce the risk of compromising their accreditation status. Joint Commission accreditation requirements, for example, require that organizations have in place appropriate risk assessment measures and processes for continuing care, treatment, and services after discharge or transfer.

Step 1: Conducting the suicide risk assessment and screening

TJC recommends that providers integrate into their existing patient screening processes certain objective tools for assessing and detecting suicide risk. TJC recommends that providers adopt the following 3-prong approach to screening and risk assessment:

• Conduct a backward-looking review of the patient's personal and family history for suicide risk factors.
• Adopt a standardized, evidence-based screening tool for detecting patients at risk for suicide. TJC recommends distributing a waiting room questionnaire at intake rather than relying solely on the clinician assessment, which is largely based on personal judgment.
• Analyze and review the screening questionnaires before the patient leaves the appointment or is discharged to determine whether immediate follow-up care is needed. For patients who screen positive for suicide ideation based on an review of the screening questionnaire and the clinician assessment, providers should request the patient's permission to contact friends, family, or other outpatient resources. If the patient poses an immediate danger to his or her self or others, the Health Insurance Portability and Accountability Act (HIPAA) enables the provider to make these contacts without the patient's consent.

Step 2: Implementing immediate safety measures and continuity of care planning

Based on the assessment results under Step 1, TJC recommends that providers take action to develop a continuity of care plan for patients in acute suicidal crisis and for patients at lower risk for suicide. For patients in acute suicidal crisis, TJC suggests keeping the patient in a safe environment and providing these patients with immediate access to care through an emergency department, psychiatric care, or other resources. For patients at lower risk for suicide, providers should make direct referrals to outpatient behavioral health care and other providers, and should not leave the decision for follow-up to the patient. Continuity in patient care transitions is key to developing a successful patient care plan that reduces suicide risk.

Step 3: Developing a collaborative behavioral health treatment plan

Developing a standardized, evidence-based screening tool for detecting suicide risk at intake will result in increased early detection. After intake, however, subsequent treatment of individuals at risk for suicide requires collaboration among numerous providers, family, and outside resources. TJC recommends that providers use a "risk formulation model" – i.e., a probability judgment expressed as low, moderate, or high – to develop a personalized intervention plan for patients.

TJC also states that providers often treat the underlying depression or mental health condition without directly addressing the patient's risk for suicide. During the discharge planning process, TJC emphasizes that providers should incorporate evidence-based interventions (e.g., cognitive therapy for suicide prevention) specifically targeting suicide risk in addition to traditional treatment for depression or other mental health conditions.

Step 4: Developing educational and training tools for providers and staff

Finally, TJC urges providers to develop educational resources for providers and staff that address how to communicate with and treat patients at risk for suicide. Educational resources should address environmental risk factors for suicide and policies for emergencies, referrals, treatment, and safety (for both patients and staff). TJC also urges providers to maintain accurate and detailed documentation of every step in the decision-making process, including an explanation of why the patient is at risk for suicide, why a specific treatment plan was chosen, the content of any safety plan, and communications with family members or other providers.

*Blake Walsh is admitted only in Tennessee. Her practice is supervised by members of the firm admitted in the District of Columbia.