NSPL’S MISSION
To effectively reach and serve
all persons who could be at risk
of suicide in the United States
through a national network of
crisis call centers.
NSPL Administrator and
Partners
• Link2Health Solutions, Inc.—
wholly owned subsidiary of MHA
of NYC ; grant since Sept 2004
• Partners:
 National Assoc. of State Mental
Health Program Directors
(NASMHPD; since 2004)
 MHA of NYC (since 2005 when
grant transferred to subsidiary)
 Living Works (2006-ongoing)
WHERE ARE LIFELINE’S
CENTERS LOCATED?
How the NSPL Works
• Caller dials 800-273-TALK or 800SUICIDE
• Calls are free and confidential
• NEAREST of 143 CENTERS (all are
independently operating agencies)
- Listen, Assess
- Support, Refer or Link to services
• Back-up centers to assure all calls
answered
• >57,000 calls per month (JULY
2009)
Veterans Suicide Prevention
Hotline
1-800-273-TALK, Veterans Press 1
• JULY 2007: VA AND SAMHSA
LAUNCH FIRST NATIONAL SUICIDE
HOTLINE FOR VETERANS
• CALLS ROUTED THROUGH 800273-TALK (press 1)
• 24-7 ACCESS TO TRAINED
COUNSELORS at VA
• NSPL CENTERS BACK-UP SERVICE
• > 10,000 calls per month
NSPL Advisory Bodies
ConsumerSurvivor
Subcommitte
e
SAMHSA
Lifeline
Network
Centers
Steering
Committee
Standards,
Training &
Practices
Subcommitte
e
Helping Callers
at Imminent
Risk of Suicide
Values, Policies
and Guidelines
NSPL: Why the Need For EI
Policies and Guidelines?
– Procedures for life-saving central to
suicide hotlines
– Variability in network center
approaches require some uniform
guidelines
– Research from Mishara, Gould &
Kalafat
– Suicide Risk Assessment Standards
= Need for Intervention Guidelines
Development of
Values, Policies and Guidelines:
Lifeline Process
• Review and Discussion Towards
Policy/Guideline Development
– CTS meetings (10/2006 on)
– Steering Committee meetings
(11/2006 on)
– AAS EI workshops with crisis centers
(2006 & 2007)
– Legal review: Link2Health and
SAMHSA
– Background paper submitted to
SAMHSA for final review (2009)
NSPL Values Regarding
Emergency Intervention
The National Suicide Prevention
Lifeline promotes:
•
Taking all action necessary to
secure the health, safety and well
being of the individuals it serves
•
Use of least invasive course of
action
•
Collaboration with community
crisis and emergency services
Definition:
Imminent Risk
• When the Center Staff responding to
the call believe, based on information
gathered during the exchange from the
person at risk or someone calling on
his/her behalf, that there is a close
temporal connection between the
person’s current risk status and actions
that could lead to his/her suicide……that
is, if no actions were taken, the Center
Staff believe that the Caller would be
likely to seriously harm or kill him/her
self.
Definition:
Imminent Risk (cont.)
…Imminent Risk may be
determined if an individual
states (or is reported to have
stated by a person believed to
be a reliable informant) both a
desire and intent to die and
has the capability of carrying
through his/her intent (see
NSPL Standards).
Helping Callers at
Imminent Risk of Suicide
• Policy and Guidelines for
Telephonic Practices
– Nine supporting guidelines
• Policy for Establishing and
Maintaining Collaborative
Relationships with Local Crisis and
Emergency Services
Policy and Guidelines for
Telephonic Practices
Center Staff shall actively engage Callers
and initiate any and all emergency
intervention measures necessary—
including active rescue—to secure the
safety of Callers determined to be
attempting suicide or at Imminent Risk of
suicide.
Guideline #1
Active Engagement
•
Actively engage callers
•
Establish rapport
•
Promote the caller’s collaboration
Definition:
Active Engagement
• Intentional behaviors undertaken by
Center Staff to effectively build an
alliance with the Callers at Imminent
Risk towards mutual understanding and
agreement on actions necessary to
successfully reduce Imminent Risk or
accept medical interventions when the
person is in the process of a suicide
attempt.
Background:
Active Engagement
Mishara et al (2007) analysis of 18
network centers showed:
•
In 15.6% of monitored calls at least
one helper rating related to support
was unacceptable
•
In 10/33 calls where a suicide
attempt was in progress helpers did
not try to engage the caller to stop
the attempt
Guideline #2
Least Invasive Intervention
•
Consider involuntary emergency
interventions as a last resort
•
Seek collaboration
•
Include the caller’s wishes, plans,
needs and capacities towards
acting on his/her own to reduce
his/her risk of suicide
Background:
Least Invasive Intervention
• Currently 62% of NSPL center policies
explicitly address “least invasive
interventions”
• Study of 8 centers (Gould et al, 2007):
– nearly 12% of the callers spontaneously
reported that the call “prevented them
from killing or harming themselves”
– Of 44 who reported a “lifesaving effect”,
only two received emergency rescue
• NSPL attempt survivor focus group:
– “I am less likely to feel that a call to 911
saved my life as much as, say, just
being listened to”
Background:
Least Invasive Intervention
NSPL attempt survivor focus
group:
– “I am less likely to feel that a
call to 911 saved my life as
much as, say, just being
listened to.”
Example:
Least Invasive Intervention
• Obtaining agreement from the
Caller
– to take actions on his/her own behalf
– to involve a significant other
– to a three-way call with a treating
professional
– to receive an evaluation in the home
by a mobile crisis/outreach team
• Securing transportation to ER
• Contacting public safety officials
to facilitate a home visit
Guideline #3
Life-saving Services for
Attempts in Progress
• Ensure caller receives emergency
medical care if attempt is in
progress
• Make reasonable efforts to obtain
caller’s consent
• Consent is not necessary in order
to initiate emergency rescue
Background:
Life-saving Services for
Attempts in Progress
• Inconsistent emergency
intervention
• Gould et al (2007)
– evaluated 1,085 calls at 8
centers
– 54 of 88 cases (61.4%): no
rescue sent when suicide
attempt in progress
Background:
Life-saving Services for
Attempts in Progress
• Mishara et al (2007)
– listened to 2,611 calls at 16
centers
– 33 cases: suicide attempt in
progress
• 6 cases emergency services sent
• 8 cases caller stopped attempt
• 9 cases caller refused help and no
emergency services sent
• 10 cases no attempt to have caller
stop & no emergency services sent
Guideline #4
Active Rescue
•
Initiate emergency rescue if a
caller is at Imminent Risk of
suicide but is unwilling/ unable
to take actions to prevent
his/her suicide
Definition:
Active Rescue
• Actions undertaken by Center staff that
are intended to ensure the safety of
individuals at Imminent Risk or in the
process of a suicide attempt. “Active”
refers to the Center staff’s initiative to
act on behalf of individuals who are in
the process of an attempt or who are
determined to be at Imminent Risk, but
who, in spite of the helper’s attempts to
actively engage them, are unwilling or
unable to initiate actions to secure
his/her own safety.
Background:
Active Rescue
•
Reasons for instituting a network
guideline
Choice to contact service
– Cognitive constriction
– Ambivalence
– Significant others
–
Similar to AAS active intervention
• 99% of centers practice a form of
‘active intervention’
•
Guideline #5
Third-Party Callers
• Actively engage the third-party
caller towards determining the
least invasive, most collaborative
actions to ensure the safety of the
at-risk individual
– Consider third-party anonymity
Background:
Third Party
•
Data from 4 network centers:
–
8.3% of calls from 3rd party
81% of network have a policy to
actively respond to third parties
• Concern regarding possible
increased risk
•
Recommended Procedure:
Third Party
•
Whenever possible, gather the
following information from the
third party caller:
–
–
–
Relevant information in the individuals
risk status
Contact information of the third party
caller and relationship to person at
risk
Obtain contact information for the
person at risk
Recommended Procedure:
Third Party
Facilitate three way call with third
party and person at risk
• Facilitate three way call with third
party and treatment professional
• Confirm that third party is willing/
able to take actions to reduce risk:
•
–
–
–
–
–
Remove access to weapons
Maintain close watch
Escort to treatment
Collaborate with MCT
Use information provided
Recommended Procedure:
Third Party Anonymity
•
NSPL recommends only preserving
anonymity in those unusual
situations when:
–
–
To reveal the identity of the third party
may aggravate risk to either third
party or other (e.g. victim of domestic
violence)
The identity is less relevant than the
report of a clear and present risk (e.g.
stranger reports a person on a bridge)
Guideline #6
Supervisory Consultation
•
Supervisory staff available for
consultation during all hours of
center operation
–
Includes staff that regularly act in a
managerial or training capacity,
with knowledge of the most current
policies and procedures….Peers
(with no other official designation
or routine role as staff supervisor
or trainer) acting as consultants are
not sufficient to meet this
requirement.
Guideline #7:
Caller I.D.
• Some method of identifying
caller’s location in real time
– Caller I.D.
– Real Time Call Trace
Background:
Caller ID
• Gould et al (2007) evaluation of
eight centers found crisis staff
unable to initiate recue for 8 of 54
callers due to no caller ID
• 91% of NSPL centers currently
use caller ID as a “tool to rescue”
Guideline #8:
Confirmation of Emergency
Services Contact
•
When center initiates active
rescue, confirm that emergency
services have made contact with
at-risk individual
Background:
Emergency Service Contact
•
Currently 54% of NSPL centers
can confirm emergency contact
•
LifeNet NYC data for 1997 –
1999 showed:
– 33% of active rescue calls did
not result in transport
Example:
Emergency Service Contact
•
Steps to confirm emergency service
contact may include:
Staying on
– Contacting
– Contacting
– Contacting
– Contacting
– Contacting
–
line with caller
local PSAP
ED or MCT
treating professional
caller directly
significant other
Guideline #9:
Follow-Up When
Emergency Services
Contact is Unsuccessful
• Take additional steps to address
the safety of the at-risk
individual when emergency
services do not make contact
Policy for Establishing &
Maintaining Collaborative
Relationships with Local
Crisis & Emergency Services
Centers shall establish
collaborative relationships (formal
and/or informal) with one or more
crisis or emergency service
providers in their community
Example:
Crisis & Emergency Services
• Police departments
• Fire departments
• County sheriff offices
• Mobile crisis/psychiatric outreach
teams
• Hospital emergency departments
• 911
• Emergency Medical Services
Example:
Formal/Informal Relationships
• Formal
– Cooperative agreement
– MOU
– Relationship officially authorized by a
local government entity
– Intra-agency policy
• Informal
– Regular communications with local
emergency or crisis services
– Exchange of education materials
– Training of local emergency staff
CRISIS CENTER EMERGENCY
RESCUES:
A MODEL for
INFORMATION EXCHANGE
BETWEEN THE CALLCENTER,
911 &
EMERGENCY DEPARTMENTS
IN NYC
MOU ISSUED BY CITY TO
ALL ENTITIES:
IF LIFENET NYC CALLS 911,
then…
 911 gives Lifenet a ref. # for call
 Lifenet calls for disposition,
using ref #
 Was the caller transported or not?
 If transported, to which hospital ED?
 Lifenet calls ED for admission
status
 Lifenet reports to City about
transports and admissions
PURPOSE OF M.O.U.
• Track continuity of care for
high risk callers in need of
emergency service
• 1997-1999:
33% of 911 calls not
transported (Lifenet sends
mobile teams to follow-up)
Half of transported callers
not admitted to the hospital
NEW LIFENET PROTOCOL,
1999
TO IMPROVE E.D. ASSESSMENT
OF TRANSPORTED CALLERS,
LIFENET WILL :
• Fax Caller information about
risk to receiving ED
• Call the ED staff to ensure fax
was received
Need for Confirming
Emergency Service
Contact (Example)
LifeNet NYC Transports
and Hospital Admission
Rates for Callers
Needing Emergency
Rescue, 1997-2004
70
P
E
R
C
E
N
T
A
G
E
S
60
50
Not Transported
40
Admitted
Not Admitted
30
20
10
0
1997
1998
1999
2000
2001
2002
2003
2004
639 complete records for rescue calls, 1997-2004
LIFENET E.D. PROTOCOL
EFFECTS
1997-2004
More risk information from Lifenet to E.D.
resulted in:
•52% increase in admission rates 1st year
after protocol implementation
•Trend towards more admissions each year
•116% higher admission rates in 2004
compared to 1998
Will 911 Call Centers Provide
Information to Crisis Centers?
National Emergency Number Association
(NENA):
• Few 911 centers routinely report externally
on transport status
• Some fear it is a HIPAA violation
• Would require crisis centers developing
local collaborations with 911
• A NENA Standard Operating Procedure
(SOP) for Lifeline centers would help
collaborations to develop
NSPL Confidentiality
Statement
• NSPL is committed to maintaining
the confidentiality of callers to the
network.
• The confidentiality of any
information disclosed during a call to
one of the NSPL centers will be
upheld at all times. The only
potential exception to preserving
confidentiality is in the circumstance
in which an individual is at imminent
risk of injury or death.
WHAT HIPAA SAYS:
“A covered entity can…use or disclose
protected health information, if the covered
entity…believes the use or disclosure: (I)(A)
Is necessary to prevent or lessen a serious
and imminent threat to health or safety of a
person or the public; and (B) Is to a person or
persons reasonably able to prevent or lessen
the threat; or (ii) Is necessary for law
enforcement authorities to indentify or
apprehend the individual”….
OCR/HIPAA Privacy/Security Enforcement
Regulation Text, 45 CFR 164.512(j)
INFO EXCHANGE FOR CARE
CONTINUITY :
• Standard practice for psychiatrists to
counsel family or caretakers of potentially
self-harming persons about risks, potential
methods, and actions to reduce risk
• Gross v. Allen, 1994: Caretakers of patients
with a history of self-harm are legally
responsible for informing the individual’s
new caretakers (not a Tarasoff-like “Duty
to Warn”, but “common-sense practice”)
Robert Simon, M.D., Psychiatric Legal
Expert, 2004
NENA S.O.P. DRAFT
• Information about Lifeline
and its network of centers
• Encourages 911/crisis
center collaboration for
continuity of care
• Adresses HIPAA as nonprohibitive
• Specifies recommended
procedure
NENA-LIFELINE S.O.P.
RECOMMENDED PROCEDURE
•911 Center devise method for
communicating disposition status to
crisis center
•Provide information about whether caller
was seen and assessed (“contact made”)
by rescue service
•If caller was transported for further
evaluation, communicate name of
receiving facility
NEXT STEPS FOR
NENA -LIFELINE S.O.P.
• Feb 2009: Lifeline met with NENA
Ops. Council
• 2nd draft being re-drawn with
workgroup of 911 Directors
• Likely to be completed by end of 2009
• S.O.P to be disseminated to all 911
and Lifeline centers in 2010
Timeline for Lifeline
Policies & Guidelines
Implementation
• Policies, background paper,
and center guidelines
distributed
• One year for implementation
• Calls to individual centers to
review implementation and assess
readiness
• Ongoing TA to individual
centers
• Webinars
• Blog
• Sample guidelines
IMPLICATIONS
of LIFELINE
POLICIES AND
GUIDELINES FOR
HELPING CALLERS
AT IMMINENT RISK
OF SUICIDE
WILL THEY CHANGE
HELPER PRACTICES?
• Ongoing evaluation
• Lifeline TA:
ASIST Trainings (ongoing)
Computer simulations
(2011?)
• Quality Improvement
Monitoring Standards
(2011?)
WILL THEY
CREATE
MORE OR LESS
CALLS TO 911
FROM
CRISIS CENTERS?
WILL THEY AFFECT
STANDARDS OF
CARE IN
BEHAVIORAL
HEALTH OVERALL?
CONTACT
INFORMATION
John Draper, Ph.D.
Director
National Suicide Prevention
Lifeline
(212) 614-6357
jdraper@mhaofnyc.org
www.suicidepreventionlifeline.org