Suicide Prevention in
Integrated Medical Settings
Tuesday, March 10, 2015
Julie A. Rickard, PhD
Physician and Healthcare Coaching
Wenatchee, WA
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
The Journey
• Clinical Health Psychologist working at Columbia
Valley Community Health (CVCH) for 10 years
• Director for the Behavioral Medicine Department
• Started the Integrated Primary Care Model at CVCH
– Working collaboratively with Primary Care Providers
– Up to 75% of unfounded psychosomatic complaints are
driven by psychological issues
– Psychologists meet with the patient within 15 minutes
of acute issue
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Suicide Prevention Coalition
of North Central WA
• Founded the SPCNCW due to increase in
suicides in Chelan/Douglas counties in 2012
• Zero tolerance for suicides within our
community through prevention, training,
education, & reducing stigma
• Philosophy on united approach to learning
through use of 1 prevention program vs.
multifaceted approach…
– Community leaders involved
– Adopted QPR Institute prevention model
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Scope of the Problem
Chelan/Douglas Counties
38
30
Chelan
Douglas
Both
30
23
15
8
0
2006
2007
2008
2009
2010
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
2011
2012
2013
2014
2015
Tuesday, March 10, 2015
Curve of Forgetting
• Curve of forgetting – People retain ~2-3% of
information after 1 mth of time without
reviewing it. Learning requires repetition.
• The more the same information is repeated
overtime the more info is retained long-term
• Repeat the same QPR training throughout the
community over the course of years and the
theory supports information being retained
long-term by participants
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Pro-Social Messaging
• Social Learning Theory (Bandura, 1977)
Viewing modeled behaviors results in imitation
of those behaviors, emotions, and/or problem
solving.
• Prosocial Messaging
– Seeing socially acceptable ways to behave
– Problem solving with solutions
– Correcting the inaccurate perceptions on
statistics and sending messages to those in need
that peers find solutions and get help
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Specific Training
• QPR Gatekeeper Instructors - Trained 29 people
in 8 sectors
– Police/fire, probation/jail, Hispanic, mental
health, education, faith, medical, stay at home
parents
– Each Instructor agreed to train 80 people in their
sector (Total of 2,320 people trained)
• Total of 3,215 people trained in 1 year
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
QPRT
4 QPRT Instructors trained locally through grant funds
Mental Health Clinicians
• Matt Adler (HB2366) - 110 clinicians have been
trained in Chelan/Douglas counties this year
• 120 more by year end
Medical Providers
• (HB2315) – 500+ medical providers by years end
• Training will begin June 2015
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Medical Issues
• Medical providers are often under-skilled at
managing suicidal patients
• Even with integration of mental health,
behaviorists are underutilized
• What you aren’t comfortable with … you avoid
• Patients are not consistently screened
– Cherry picked – crying, sad, commenting
– Patient Health Questionnaire (PHQ-9)
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Medical Issues
• Most frequent call from a new medical provider
is regarding suicidal patient management
• Encounter driven system that doesn’t
accommodate interruptions or extra time with
patients
– Don’t ask don’t tell
– Up to 75% of completed suicides presented to their
PCP the month prior to their death
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Medical Issues
• Lack of support from admin to change the
system and ensure appropriate screening
– PHQ Story
– PCP not talking to me for 2 years
– Written up
• Requires a culture shift in medicine
• Medical providers seek out guidance from
behaviorist for difficult patient issues
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Medical Providers
• Up to 50% of pts present with unfounded
psychosomatic complaints at any given time (Edwards, 2010)
• Bulk of psychopharmacology medications are
prescribed by primary care
• Under skilled at treating mental health issues
• Under skilled at suicide management
• Under skilled at difficult conversations (saying no)
• Under skilled at managing difficult patients
• Improved skill increases provider & pt satisfaction
– Improves litigious actions
– Improves safety
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Coaching Model
• Initially assigned 4 medical providers
– 2 MDs that precepted 2 new mid-level providers
• Meet biweekly for 3 mths and then monthly
after that for up to 1 year
• Shadowing providers 0, 3, 6, 12 mths
• Pre/post screening questionnaire
• Within 1 quarter patient satisfaction scores
improved for established providers by 20+%
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Coaching Model
• Notable benefits on provider/staff relationships
– Retention
– Job satisfaction
– Working at top of license
– Improved relationships with providers
• Improved competence in area of suicidal
ideation, difficult conversations, saying no,
agenda setting, etc.
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Coaching Expanded
• Model is now expanded to ALL NEW medical
providers starting and issues related to satisfaction
surveys/evaluations
• Incorporate suicide prevention training clinic wide
at the time providers/staff start
• Expanded to pods/teams
• Teaching to Lean / Flow process
• Expanded to nurses and medical assistant training
in communication with medical providers, running
meetings, managing difficult patients
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Coaching into the Future
• Transferring medical centers to Confluence
Health Systems (5000 employees)
• Build a medical provider coaching program for
the 1500 medical providers which includes
suicide prevention as a regular part of the
curriculum
• Train psychologists and mental health clinicians
as coaches to assist in building the program and
working with providers
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
• Identify medical providers as leaders to
shadow and mentor new providers
• Create inpatient/outpatient nursing protocol
for suicidal patients
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
Julie A. Rickard, PhD
Physician & Healthcare Coaching
jrickard@charter.net
509-881-8193
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015
References
1.Bandura (1977). Social Learning Theory
2.Edwards, T. et al. (2010). The treatment of patients with medically unexplained
symptoms in primary care: a review of the literature. Mental Health Family Medicine.
2010 Dec; 7(4): 209–221. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083260/.
3.Fazekas, et al. (2009). Psychosomatic medicine in primary care: influence of training.
4.Kohn, A. (April 2014). Brain Science: Overcoming the Forgetting Curve. Learning
Solutions Magazine. http://www.learningsolutionsmag.com/articles/1400/brainscience-overcoming-the-forgetting-curve.
ACHIEVING ZERO SUICIDE FOR OUR INLAND NORTHWEST COMMUNITIES
Tuesday, March 10, 2015