DETERMINING PRIORITY FOR ACTION AND REFERRAL

Once an assessment of the patient’s level of risk, lethality, and access to means have been completed, the next step is to determine the priority for action and where intervention can best be achieved. Disposition is determined according to level of risk:

High risk: Patients who have a psychiatric diagnosis with severe symptoms or an acute precipitating event, have made a potentially lethal suicide attempt or have persistent ideation with strong intent or suicide rehearsal generally should be managed with suicide precautions and admitted to a hospital for management.
Moderate risk: Patients with multiple risk factors and few protective factors, who have suicidal ideation with a plan but no intent or behavior, may require referral for a more in-depth evaluation or hospital admission. If not admitted, a crisis plan should be developed and the patient should be given emergency/crisis numbers.
Low risk: Patients with modifiable risk factors and strong protective factors who have thoughts of death, no plan, intent, or behavior should be referred for outpatient management and be provided with emergency/crisis numbers.
(SAMHSA, 2020)

Models of Care for Patients at Risk for Suicide

During triage, the appropriate intervention is selected, and there are several models of care to consider. A model of care is a set of interventions that can be consistently carried out in various settings to ensure that people get the right care, at the right time, by the right provider or team, and in the right place. Newer models of care for management of patients at risk for suicide include:

Crisis support and follow-up
Brief intervention and follow-up
Suicide-specific outpatient management
Emergency respite care
Partial hospitalization with suicide specific care
Inpatient hospitalization
(SPRC & NAASP, 2019)

CRISIS SUPPORT AND FOLLOW-UP

Crisis support and follow-up can include mobile crisis teams, walk-in crisis clinics, hospital-based psychiatric emergency services, peer-based crisis services, and other programs designed to provide assessment, crisis stabilization, and referral to an appropriate level of ongoing care. Crisis centers can also serve as a connection to the patient between outpatient visits. A full range of crisis services can reduce involuntary hospitalizations and suicides when paired with mental health follow-up care (SPRC & NAASP, 2019).

BRIEF INTERVENTION AND FOLLOW-UP

Brief intervention and follow-up are used when contact is limited and can be done in a single session or over several sessions. This involves teaching, informing, and education along with planning for future crises. Outreach and follow-up are provided through phone calls, letters, and texts. This model may also include the development of a safety plan (SPRC & NAASP, 2019).

SUICIDE-SPECIFIC OUTPATIENT MANAGEMENT

Suicide-specific outpatient management involves intensive outpatient programs that may require appointments three days per week for three to four hours per day for patients with elevated but not imminent risk who express a desire to die by suicide but do not have a specific plan or intent and need aggressive treatment (SPRC & NAASP, 2019).

EMERGENCY RESPITE CARE

Emergency respite care is an alternative to inpatient or emergency department services for a person in a suicidal crisis when the person is not in immediate danger. Respite centers are usually located in residential facilities designed to be more like a home than a hospital. These facilities may include staff members who are peers who have lived experience of suicide. Respite care is increasingly being utilized as an intervention and may include help with establishing continuity of care and provision of longer-term support resources, as well as support by text, phone, or online following a stay (SPRC & NAASP, 2019).

PARTIAL HOSPITALIZATION WITH SUICIDE-SPECIFIC CARE

Partial hospitalization with suicide-specific care involves provision of treatment for six or more hours every day or every other day while the patient continues to live at home.

INPATIENT BEHAVIORAL HEALTH HOSPITALIZATION

Inpatient behavioral healthcare is brief hospital treatment for individuals who may be at high risk of suicide and who have made a suicide attempt. The emphasis is on keeping the patient safe while in the hospital and immediately following discharge (SPRC & NAASP, 2019).

Referring the Suicidal Patient

Clinicians who are the initial contact for patients who are at risk or who have made a suicide attempt most often refer them to one of the available treatment options, depending upon degree of risk.

A patient who is in acute suicidal crisis should be kept in a safe healthcare environment under one-to-one observation while arranging for immediate transfer to an emergency department. In certain instances where a patient is not willing to comply with disposition recommendations or is unwilling to provide informed consent for treatment, it then becomes the responsibility of the clinician to protect the patient by contacting legal authorities for assistance (TJC, 2016; Washington State Legislature, n.d.).

Other patients may require a referral to behavioral health for further evaluation and treatment. Making such a referral requires a smooth and uninterrupted transition of care from one setting to another. In order to ensure that the patient is linked to appropriate care, the referring clinician follows these steps:

Refer the patient to an outpatient provider for an urgent appointment for a date within a week of discharge.
If unable to schedule the first follow-up appointment for a date within a week of discharge, refer for follow-up with a primary care provider and contact the primary care giver to discuss the patient’s condition and reason for referral.
Institute or revise a patient’s safety plan before discharge or referral.
Ensure that the patient has spoken by phone with the new provider.
Send patient records several days in advance of the appointment to the new treatment provider and call to go over patient information prior to the first appointment.
Troubleshoot the patient’s access-to-care barriers (e.g., lack of health insurance, transportation needs) using information from the community resources list.
Contact the patient within 24 to 48 hours after they have transitioned to the next care provider and document the contact.
(SPRC, 2019d)