New York Academy for
Suicide Safer Care
(NYASSC)
Resource
Directory
2015
Jillian King, Ed.M.
In collaboration with Suicide
Prevention Resource Center
(SPRC)
New York Academy for Suicide Safer Care, (NYASSC), 2015
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Table of Contents
NY ASSC Overview……………………………………………………………………………………...…3
NSSP Grant Overview…………………………………………………………………………..……..…..3
AIM Model……………………………………………………………………………………………..……..4
Assess – Resources and Links
Columbia- Suicide Severity Rating Scale)….……………………………………………....……5
SAFE-T……………………………………………………………………………………………….6
Intervene – Resources and Links
Safety Planning………………………………………………….……………………….……....…7
Lethal Means Counseling………………………………………………………………….…......10
Monitor – Resources and Links
Structured Follow-up Intervention…………………………………………………………….….12
Caring Contacts……………………………………………………………………………………15
Attempt Survivor Resources……………………………………………………………………...17
Additional Resources and Links……………………………………………………………………….18
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New York Academy for Suicide Safer Care (NY ASSC) Overview
In 2013, the most recent year for which data are available, over 40,000 people died by suicide,
making it the 10th leading cause of death in the U.S. Over the same time period, New York
ranks 5th among all states in total suicides completed. And perhaps most alarming is the high
suicide rate among those suffering with mental illness, including OMH consumers.
Unfortunately, even in behavioral health settings, we have not been able to develop the
systemic response required. Work force surveys indicate over 40% of mental health clinicians
do not feel adequately trained to manage suicidal behavior. Otherwise skilled and competent
clinicians generally do not receive adequate training in the focused assessment and
management of suicide risk.
But the situation is far from hopeless. While much remains to be learned, the core components
of “suicide safer care” are known and should be adopted now.
As part of the National Strategy for Suicide Prevention Grant, the New York Academy for
Suicide Safer Care (NY ASSC) aims to markedly raise the standard of care delivered to those at
risk for suicide. This pilot program offers a learning collaborative for providers willing to make an
enduring commitment to the system change needed to materially improve outpatient care in this
area.
New York National Strategy for Suicide Prevention Grant Overview
The New York State Office of Mental Health (OMH) was awarded a grant by the Substance
Abuse and Mental Health Services Administration (SAMHSA) to advance the National Strategy
for Suicide Prevention (NSSP) in middle-aged adults. New York was one of only four states to
receive this award.
Grant Description:
 The grant advances two cornerstone objectives from the National Strategy for Suicide
Prevention:
o Promoting suicide prevention as a core component of health care
o Promoting and implementing effective evidenced-based assessments
and treatments for those at risk
Grant Stewardship:
 Dr. Sigrid Pechenik, PsyD, a psychologist for OMH Child and Adult State Operations
 Suicide Safer Care Implementation, and Dr. Jay Carruthers, MD, a psychiatrist &
Director of the OMH Suicide Prevention Office (SPO) are grant co-directors
 Dr. Barbara Stanley, PhD, from the Center for Practice Innovations (CPI) at Columbia
University and NYS Psychiatric Institute will be the clinical director. Dr. Stanley is an
internationally known expert in suicide prevention.
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Approach:
To achieve the NSSP grant objectives, OMH will do the following:
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New York State will advance the National Strategy for Suicide Prevention by forming an
Academy for Suicide Safer Care to engage organizations’ leadership to commit to a zero
suicide goal.
Grant activities will show a reduction of 10% in the number of suicide attempts and
deaths by developing and implementing rapid follow up and care transitions protocols
after discharge from psychiatric EDs and inpatient settings.
OMH will elevate suicide identification, intervention and treatment skills among staff and
community organizations servicing persons at high risk of suicide attempts.
OMH will develop a plan to measure and demonstrate the impact of grant activities on
adult suicide deaths and attempts.
Utilize the AIM (Assess, Intervene, and Monitor) framework for high suicide risk
individuals developed by Dr. Stanley.
Implement the AIM model in high risk settings beginning with inpatient psychiatric units
and ERs/CPEPs for those experiencing a suicidal crisis where assessment, safety
planning with means restriction and structured follow-up serve as a package of evidence
based tools. The care transition will include Structured Phone Follow-up, Warm Transfer
and Peer Services.
Disseminate lessons learned through the ongoing work of the Suicide Prevention Office.
Participating Clinical Partners:
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Buffalo and Rochester Psychiatric Centers
Erie County Medical Center
University of Rochester Medical Center/ Strong Memorial Hospital
Erie County Crisis Services
2-1-1 Lifeline in Monroe County
AIM Model
A
Assess
• Columbia Suicide Severity Rating Scale (CSSR-S)
• Suicide Assessment Five-step Evaluation and Triage
(SAFE-T)
• Cage-Aid
• Or assessment tool currently used
I
Intervene
Safety Planning Intervention (SPI) with means restriction
M
Monitor
Structured Follow-up post discharge (SFU)
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Assess – Resources and Links
1. Columbia- Suicide Severity Rating Scale
•
C-SSRS Website
http://www.cssrs.columbia.edu/
•
Online module for the C-SSRS
http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/c
ssrs_web/course.htm
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2. Suicide Assessment Five-Step Evaluation and Triage (SAFE-T): Pocket Card for
Clinicians
 SAFE-T Pocket Card
http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-TriageSAFE-T-Pocket-Card-for-Clinicians/SMA09-4432

Suicide Safe: The Suicide Prevention App for Health Care Providers from SAMHSA
http://store.samhsa.gov/apps/suicidesafe/index.html
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Intervene – Resources and Links:
1. Safety Planning
In Safety Planning, the provider works with the patient to develop a list of coping strategies and
resources that he or she can use before or during suicidal crises. The plan is brief, in the
patient’s own words, and easy to read. Topics addressed in most safety plans include:
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Warning signs
Internal coping strategies
Ways to distract oneself from the crisis
Family members or friends who can provide support
Professionals and agencies to contact for help
Ways to make the environment safe
Safety plans may be done on paper or using a mobile phone app—if the patient has a mobile
device and is comfortable using it for this purpose (see Safety Planning Resources).
Safety planning should not be confused with contracts for safety or no-suicide contracts. There
is no evidence that these contracts are effective, and they can provide a false sense of security
(Rudd, Mandrusiak, & Joiner, 2006; Stanley & Brown, 2012).
How

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Review the Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version for an
orientation to this intervention. The guidance in this manual is suitable for all patient
populations.
Tell the patient that you recommend developing a safety plan. Decide together if you will
develop it jointly or if he or she will develop the plan independently and then review it with
you before discharge. With the patient’s permission, involve his or her family, friends, and/or
a peer specialist.
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Use one of the tools listed under Safety Planning Resources (following) to develop a safety
plan.
Identify potential barriers or obstacles to using the safety plan and determine how to
overcome them.

Tell the patient that although safety plans are important for coping with suicidal thoughts or
feelings outside of the treatment setting, getting outpatient mental health care can address
what’s making him or her feel suicidal.
Instruct the patient to review the safety plan with an outpatient provider. Provide a copy for
each.
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Safety Planning Resources

Safety Planning – A quick Guide for Clinicians - G. Brown and B. Stanley, Department of
Veterans Affairs
http://www.sprc.org/sites/sprc.org/files/SafetyPlanningGuide%20Quick%20Guide%20for
%20Clinicians.pdf

Safety Plan Treatment Manual to Reduce Suicide Risk - G. Brown and B. Stanley,
Department of Veterans Affairs
http://www.mentalhealth.va.gov/docs/VA_Safety_planning_manual.pdf?_sm_au_=iVV0T
TM8VDT8jSPH

Patient Safety Plan template - G. Brown and B. Stanley, Department of Veterans Affairs
http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf
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Safety Plan Mobile App - New York State Office of Mental Heath
https://www.omh.ny.gov/omhweb/suicide_prevention/safety/
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ED-SAFE Materials - Safety Planning Resources
http://emnet-usa.org/ED-SAFE/materials.htm

MY3 Support System and Safety Planning Mobile App - Link2Health Solutions and the
California Mental Health Services Authority
http://www.my3app.org/?_sm_au_=iVV0TTM8VDT8jSPH
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2. Lethal Means Counseling
In Lethal Means Counseling, the provider assesses whether a patient at risk for suicide has
access to firearms or other lethal means (e.g., prescription medications), and works with the
patient and his or her friends, family, or outpatient provider to discuss ways to limit this access
until the patient is no longer feeling suicidal.
How
 Tell the patient and his or her friends or family that suicide risk can sometimes escalate
rapidly, so it is important to consider the patient’s access to lethal means during these
periods of increased risk.
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Ask the patient and his or her supports about the patient’s access to lethal means,
particularly firearms. If the patient has access to firearms, ask about the location (e.g.,
closet, car, attic).

Provide appropriate counseling to patients who report having access to lethal means. For a
list of points to cover in a brief counseling session, view the Lethal Means Counseling
Recommendations for Clinicians sheet available from Means Matter. Just like any other
interviewing technique, it takes practice to become more skillful when engaging patient’s
around safe storage of firearms.

Identify strategies for limiting access to lethal means, such as storing firearms at a friend’s
house until the suicidal crisis has passed, and allowing a family member to keep
medications under lock and key and dispense them as necessary in order to prevent selfpoisoning.
Lethal Means Counseling Resources
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Recommendations for Clinicians – Lethal means counseling, Means Matter, Harvard
School of Public Health
Recommendations for Families – Information on lethal means, Means Matter, Harvard
School of Public Health
Counseling on Access to Lethal Means (CALM) – Online training course, Suicide
Prevention Resource Center
Firearm Safety and Injury Prevention – Policy, American College of Emergency
Physicians (ACEP)
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Reducing Access to Lethal Means – Quick Guide
Working with individuals at risk of suicide is a complex process that requires a comprehensive approach.
One piece of that puzzle that has proven to be effective is to reduce access to lethal means –
particularly firearms and medications.
Three specific steps to take
1. Tell the individual and/or the family that the individual is at risk based on your assessment;
provide specific information about how you made this determination.
2. Explain that one element of lowering risk by reducing their access to lethal means.
3. Discuss specific steps they can take to reduce access to firearms and other lethal means as they
relate to their current or previous plan.
Firearms
 The MOST EFFECTIVE means for reducing suicide with a firearm is to remove all firearms from
the home and environment
 DON’T believe that the suicidal person does not know if or where weapons are stored.
 When discussing these issues, focus on the risk, not on the firearm
 If the family is reluctant to remove the firearm permanently, discuss a temporary move for a
specified period of time
 Most Police Departments will accept firearms to be destroyed, some on a temporary basis
 If moving the firearms to someone else’s care discuss specific instructions regarding who, when
and how the firearm will be handed over and returned.
 If removal is not an option, make the following suggestions:
o Store all firearms unloaded and locked
o Any ammunition should be stored and locked and separate from the firearms
Medications and Poisons
 Prescriptions and OTC medications should be limited in number to non-lethal doses
 Any medicines or other poisons not being used should be safely disposed of
 Any other potentially lethal products should be removed from the home or moved and kept
locked
 If uncertain regarding the toxicity of specific medications or other products contact the Poison
Center at 1-800-222-1222
Other Means
It may be more difficult to limit access to other means. However, it is important to take whatever steps
are indicated to reduce access when feasible if the individual talks about using any of these. These could
include- cars, trains or other vehicles, ropes or ligatures, sharp objects, alcohol and drugs.
FREE ON-LINE TRAINING: Counseling on Access to Lethal Means (CALM). This 2 hour workshop
addresses why and how to discuss the steps above http://training.sprc.org
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Monitor – Resources and Links:
1. Structured Follow-up
Structured Follow Up involves obtaining a follow-up appointment for the patient that occurs
within seven days of discharge—ideally, within 24 hours of discharge. Developing referral
agreements with outpatient providers may facilitate this process. A sample letter is provided in
Appendix E to facilitate developing these agreements. Consider the patient’s needs and
troubleshoot barriers to accessing outpatient services when choosing a referral.
How

Develop a community resource list that ED personnel can use for making referral
appointments to outpatient providers. Use the template in Appendix F or request a copy of a
list used by a local community-based organization. Highlight providers on the list who are
skilled in suicide assessment, management, and treatment.

Request the patient’s consent to provide clinical information about the ED visit to the referral
provider. See Appendix D to learn about sharing protected health information with other
providers. Use a two-way release if possible.
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Before the patient is discharged, call an outpatient provider to schedule an urgent outpatient
appointment for a date within a week of discharge. If the outpatient provider is unavailable,
plan for a second call during regular business hours or leave a message requesting priority
scheduling for the patient. If these steps fail, and with the patient’s permission, enlist a
trusted caregiver or peer specialist to help schedule the appointment.

For patients who present to the ED during off-hours, identify other ED personnel to schedule
the follow-up appointment during regular business hours.

If you are unable to schedule the first follow-up appointment for a date within a week of
discharge, consider these options:
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Refer the patient for a follow-up appointment with a primary care provider (PCP). With
the patient’s permission, contact the PCP to discuss the patient’s condition and reason
for the referral. Most PCPs are not aware of their patients’ suicidal ideation or attempts
(Riihimaki, Vuorilehto, Melartin, Haukka, & Isometsa, 2014). Ask for help in securing
outpatient mental health treatment.
Develop a protocol for working with a local crisis center to provide follow-up support for
these patients. Some crisis centers make follow-up contacts with patients who have
recently been discharged from EDs to facilitate linkages to care and provide additional
support. Crisis center services are free and open to the public.
Troubleshoot the patient’s access-to-care barriers (e.g., lack of health insurance or
transportation) using information from the community resources list.
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Rapid Referral Resources

Care Transitions: Best Practices and Evidence-based Programs – Center for Healthcare
Research & Transformation
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SP-TIE (Suicide Prevention – Training Implementation Evaluation)

http://practiceinnovations.org/CPIInitiatives/SuicidePrevention/ResourceLinks/tabid/291/
Default.aspx
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STRUCTURED FOLLOW-UP
Permission for follow-up is obtained beforehand for permission to:
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Make a follow-up call.
Conduct the call in a friendly, non-judgmental, yet professional manner.
Leave a voice mail if the person is not reached.
Step 1: Mood Check and Lethality Assessment
Step 2: Review and revision of the safety plan
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Determine if the safety plan has been used.
Ask the individual to present the safety plan for review with you.
Ask what has been helpful and what has not been helpful.
Revise the plan as indicated—remove items that are not helpful and engage the individual by
discussing what may be more helpful.
Both the clinician and the individual must note any changes on the plan.
Consider sending the suicidal individual a revised plan if the revisions are extensive.
Always review access to means and whether there is a need to remove sources of danger.
Step 3: Treatment engagement and motivation
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Review what the individual’s plans are for treatment; remind individual of appointment.
Review treatment options, as needed.
Problem solve obstacles to treatment—external (e.g., logistics) and internal (e.g., motivation).
If a person rejects treatment, discuss other ways of obtaining help.
Provide information on available community support services relevant to individual’s needs (for all
individuals, not only when treatment is rejected).
Step 4: Obtain consent/willingness for additional follow-up
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Assess whether further calls are needed.
If needed, but resisted, problem solve.
Set call time.
If no further calls, let individual know how to resurrect care.
Implementation
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Determine timing and frequency of contact.
Develop a plan if suicidal individual is consistently unreachable.
Record keeping
o Maintain a record of all contacts.
o Develop a system of notification further contact
Other Structured Follow-up Resources
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Other Follow-up Resources
2. Caring Contacts
Caring contacts are brief communications with the patient after discharge from the ED. They
may be made by the ED provider or other personnel, be one-time or recurring contacts, and
involve one-way or two-way communication. These contacts are meant to facilitate adherence
to the discharge plan and promote a feeling of connectedness by demonstrating continued
interest in the patient. Caring contacts may be especially helpful for patients who have barriers
to outpatient care or are unwilling to access this care.
How
 Follow up with discharged patients via postcards, letters, e-mail, text messages, or phone
calls. See sample messages in Appendix G. These contacts can be made by clinical staff or
non-medical ED personnel and may be automated. Phone calls will require training.
 Use automated systems for providing caring contacts, such as mailed or e-mailed postcards
or text messages (Berrouiguet, Gravey, Le Galudec, Alavi, & Walter, 2014). Some electronic
health record systems can perform these functions.
 Consider establishing an agreement with a local crisis center that allows its staff to make
caring contacts with recently discharged patients.
Caring Contacts Resources
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Postcards from the EDge: 5-Year Outcomes of a Randomised Controlled Trial for
Hospital-Treated Self-Poisoning – Journal article, G. L. Carter, K. Clover, I. M. Whyte, A.
H. Dawson and C. D’Este.
For a recent literature review see Luxton DD et al. Can Postdischarge Follow-up
Contacts Prevent Suicide? Crisis Vol 34, Number 1/2013
Post-Visit Patient Contact Improves Patient Satisfaction – Program overview, Robert
Wood Johnson Foundation.
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Caring Contacts Sample Materials
Caring contacts is an evidence-based intervention covered in Section 3 ED-Based Brief Suicide
Prevention Interventions. For hospitals wishing to implement this intervention, a few samples of
caring contact materials are provided below. These samples come from suicide prevention
professionals using caring contacts in crisis centers, hospitals, and VA settings across the
United States. They can be adapted for use in your ED and for current technology options (e.g.,
text messaging, e-mail).
Sample 1. Postcards from the EDge
Sample postcard used at Newcastle Mater Misericordiae Hospital in the “Postcards from the
EDge” study in New South Wales, Australia
Dear <<First Name>>
It has been a short time since you were here at the Newcastle Mater Hospital,
and we hope things are going well for you.
If you wish to drop us a note we would be happy to hear from you.
Best wishes,
Dr. Andrew Dawson
Source: Carter, G. I., Clover, K., Whyte, I. M., Dawson, A. H., & D’Este, C. (2005). Postcards
from the EDge project: Randomised controlled trial of an intervention using postcards to reduce
repetition of hospital treated deliberate self-poisoning. BMJ, doi: 10.1136/bmj.38579.455266.E0
Sample 2. Oklahoma City VA Medical Center
This program sends quarterly newsletters to patients at risk of suicide with information about
health and mental health. A blank space is provided in the newsletter for the case manager to
handwrite a note, such as this:
Hi Mr./Ms.____,
I hope you have been doing well since we last spoke. Give me a call
if there’s anything I can do for you.
Sincerely,
This message is in keeping with the spirit of the examples used in published studies of caring
contacts, where there is an expression of concern and no demands are made on the recipient.
To learn more, contact Bryan Stice, PhD, Suicide Prevention Case Manager, Department of
Veterans Affairs, 921 N.E. 13th Street, Oklahoma City, OK, 73104, Bryan.Stice@va.gov, 405456-5206.
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Sample 3. Caring Letters in the VA System
Sample letter from the article “Caring Letters for Suicide Prevention: Implementation of a MultiSite Randomized Clinical Trial in the U.S. Military and Veteran Affairs Healthcare Systems.”
Dear [patient’s name],
We appreciated the opportunity to get to know you while you were
at the hospital. We hope things are going well for you. We
remember how you said that you enjoy hiking around the South
Puget Sound. With the return of the summer weather, we hope
you’re getting a chance to get out there and explore some new
trails. Anyway, we just wanted to send a quick e-mail to let you
know we are thinking about you and wishing you well. If you wish to
drop us a note, we would be glad to hear from you.
Sincerely, Cassidy and Laura
Source: Luxton, D. D., Thomas, E. K., Chipps, J., Relova, R. M., Brown, D., McLay, R., . . .
Smolenski, D. J. (2014). Caring letters for suicide prevention: Implementation of a multi-site
randomized clinical trial in the U.S. military and Veteran Affairs healthcare systems.
Contemporary Clinical Trials, 37(2), 252–260. doi: 10.1016/j.cct.2014.01.007
3. Attempt Survivor Resources
The way forward: pathways to hope, recovery, and wellness with insights from lived
experience
This report gives voice to suicide attempt survivors and bridges the gap between suicide
attempt survivors, clinicians, hospital policy makers, and suicide prevention leaders.
http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Th
e-Way-Forward-Final-2014-07-01.pdf
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Additional Resources and Links:
1. Zero Suicide/Action Alliance for Suicide Prevention
http://zerosuicide.sprc.org/
o
Safety Planning Intervention Module
http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.or
g/files/sp/course.htm
o
Structured Follow-up Module
http://zerosuicide.sprc.org/sites/zerosuicide.sprc.org/files/monitor_suicidal_individ
uals/course.htm
2. Suicide Prevention Resource Center
http://www.sprc.org/
3. Suicide Prevention Center of New York
http://www.preventsuicideny.org/
4. Resources for the Collaborative Assessment and Management of Suicidality
(CAMS)
o CUA Suicide Prevention Lab:
https://sites.google.com/site/cuajsplab/home
o
Managing Suicidal Risk – A Collaborative Approach:
http://www.guilford.com/books/Managing-Suicidal-Risk/DavidJobes/9781593853273
5. Resources for Suicide-Specific Cognitive Behavioral Therapy
o Source Book:
https://www.apa.org/pubs/books/4317169.aspx
o
Cognitive Therapy Training:
www.beckinstitute.org/cbt-workshop-registration
o
Other Key Websites:
http://veterans.utah.edu/research/cognitive-behavior-therapy.php
http://www.usuhs.mil/faculty/holloway/index.html
http://www.suicidesafetyplan.com/Home_Page.html
6. Resources for Dialectical Behavior Therapy
o Source Texts:
http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/linehan.htm&dir=pp/pd
o
Training Website: http://behavioraltech.org/index.cfm
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7. Behavioral Workforce Survey Study
http://www.slideshare.net/davidwcovington/project-zero-suicide-in-health-care-2013-10
o
o
o
National survey of 30,000 mental health professionals that examined staff
members assessment of their own knowledge and skills in dealing with a suicidal
patient
Distributed across nine states
Professionals included clinicians, social workers, psychiatrists, nurses, case
managers and peer specialists
8. SAMHSA’s Suicide Prevention Resources
By creating an account at http://store.samhsa.gov/home, you will then have access to a
wealth of FREE resources. It takes approximately 4-6 weeks to receive your order,
however many are available for instant download. Following are the links to just a few of
the many publications available.
o
After an Attempt: A Guide for Medical Providers in the Emergency
Department Taking Care of Suicide Attempt Survivors
http://store.samhsa.gov/product/A-Guide-for-Medical-Providers-in-theEmergency-Department-Taking-Care-of-Suicide-Attempt-Survivors/SMA08-4359
o
After an Attempt: A Guide for Taking Care of Your Family Member After
Treatment in the Emergency Department
http://store.samhsa.gov/product/A-Guide-for-Taking-Care-of-Your-FamilyMember-After-Treatment-in-the-Emergency-Department/SMA08-4357
o
After an Attempt: A Guide for Taking Care of Yourself After Your Treatment
in the Emergency Department
http://store.samhsa.gov/product/A-Guide-for-Taking-Care-of-Yourself-After-YourTreatment-in-the-Emergency-Department/SMA08-4355
o
National Suicide Prevention Lifeline Wallet Card: Assessing Suicide Risk:
Initial Tips for Counselors
http://store.samhsa.gov/product/National-Suicide-Prevention-Lifeline-WalletCard-Assessing-Suicide-Risk-Initial-Tips-for-Counselors/SVP13-0153
o
Building Bridges: Suicide Prevention Dialogue with Consumers and
Survivors: From Pain to Promise
http://store.samhsa.gov/product/Suicide-Prevention-Dialogue-with-Consumersand-Survivors-From-Pain-to-Promise/SMA10-4589
o
Stories Of Hope And Recovery: A Video Guide for Suicide Attempt
Survivors
http://store.samhsa.gov/product/Stories-Of-Hope-And-Recovery-A-Video-Guidefor-Suicide-Attempt-Survivors/SMA12-4711DVD
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o
Suicide Assessment Five-Step Evaluation and Triage (SAFE-T): Pocket
Card for Clinicians
http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-andTriage-SAFE-T-Pocket-Card-for-Clinicians/SMA09-4432
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