Magellan Health’s Programmatic Suicide Deterrent System

1
Arizona Programmatic Suicide Deterrent System Project
Reference Guide

2
“Suicide represents a worst case failure in mental health care. We must work to
make it a ‘never event’ in our programs and systems of care.” – Dr. Mike Hogan,
New York State Office of Mental Health
About the cover
Historically, the George Washington
Memorial Bridge in Seattle, Washington
was one of the top sites in the country
for suicide deaths. In May 2009,
Governor Gregoire signed the bill
authorizing $5 million for a bridge
barrier and the eight-foot nine-inch tall
fence was completed in February 2011.
Photo by Ari Brown - © Ari Brown 2011

3
Table of Contents
ARIZONA PROGRAMMATIC SUICIDE DETERRENT SYSTEM PROJECT 4-6
GOAL AND BACKGROUND 7-8
PERSONAL STORIES 9-10
PILOT PROGRAM SUMMARY 11
BEHAVIORAL HEALTH SCREENS 12
 ADULT BEHAVIORAL HEALTH SCREEN 13-14
 ADOLESCENT BEHAVIORAL HEALTH SCREEN 15-17
 CHILDREN’S BEHAVIORAL HEALTH SCREEN 18-20
SUICIDE RISK ASSESSMENT 21
 ADULT SUICIDE RISK ASSESSMENT 22
 CHILD/ADOLESCENT SUICIDE RISK ASSESSMENT 23
SUICIDE RISK ASSESSMENT DEFINITIONS 24-25
CLINICAL DECISION SUPPORT TOOLS 26-27
 ADULT TITLE 19 SUPPORT TOOL 28
 ADULT NON-TITLE 19 SUPPORT TOOL 29
 ADULT GMH/SA SUPPORT TOOL 30
 CHILD/ADOLESCENT SUPPORT TOOL 31
 SUPPORT TOOL DESCRIPTIONS 32-35
IMMINENT RISK 36
WEAPON SAFETY SUGGESTIONS 37
CONTRIBUTORS 38
REFERENCE PAGE 39
CONTACTS 40

4
Arizona Programmatic Suicide Deterrent System Project
Multi-level suicide prevention strategies have been implemented since launching the
Arizona Programmatic Suicide Deterrent System Project in 2009. With Arizona ranked seventh
highest in the nation for the number of reported suicides, Magellan Health Services of Arizona
is focusing the spotlight on one of the most high-risk groups - those experiencing mental illness.
It is a fact that individuals suffering from severe mental illness are six to twelve times more
likely to die from suicide than
the general population.
Magellan has joined
forces with the Arizona
Department of Health
Services and Division of
Behavioral Health Services,
Magellan's network of service
providers, members of
Arizona's judicial and
legislative branches and other
community stakeholders in a
suicide prevention and
intervention initiative. The
goal is to reduce the suicide
rate in Maricopa County by
equipping behavioral health-
care staff with the skills,
knowledge, attitudes and
support to more effectively
intervene and engage with those at risk of suicide.
Magellan adopted Living Work’s Applied Suicide Intervention Skills Training (ASIST) as
the training component for its behavioral health workforce. The expectation was that, once
trained, behavioral health staff would be able to discuss freely the suicidal thoughts of the
individuals with whom they work. In this way, they could actively encourage individuals to
express their feelings and their ambivalence toward living or dying. By listening to and
understanding a person’s reasons for dying, the suicidal person will express his/her reasons for
living. Listening to both sides of ambivalence, that is, a wish to live and a wish to die, allows
staff to effectively engage the individual in realistic safety planning.

5
“Driving Suicides to Zero – Screen, Assess, Stratify, Intervene, and Follow up” is one module
within the broader Suicide Care System. Arizona Department of Health Services, Magellan, and
Maricopa County community providers have developed a comprehensive systems-based
approach to suicide care and intervention. The strategies that have been implemented assure
that care is:
i. Safe: The entire behavioral healthcare workforce is properly trained and equipped to
engage individuals at risk.
ii. Effective: We publically account for reductions in deaths for those enrolled,
improvements in workforce confidence and the impact upon cost of care.
iii. Timely: Every recipient receives a Behavioral Health Screen (for suicidality) and is
provided immediate accessibility to support staff.
iv. Efficient: Screening and assessment results, in combination with recommended
clinical decision support tools, drive frequency of contact and interventions, based
on individual need.

6
Since FY2007, the death rate (number of suicides per 100,000) has decreased 67% for all of our
behavioral health recipients, and 42% for our SMI recipients.
FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 Reduction
SMI 174.8 140.7 82.3 110.9 158.7 101.0 42%
Child 5.4 10.6 0.0 4.3 6.1 0.0 100%
GMH/SA 58.1 25.0 32.4 37.8 30.8 12.7 78%
Total BH 77.2 52.8 35.8 47.5 47.8 25.7 67%

7
Driving Suicides to Zero – Screen, Assess, Stratify, Intervene, and
Follow up
Goal
The goals of this initiative are four-fold. 1) To prepare the clinical workforce to
confidently identify those at risk for suicide. This will allow the clinical workforce to actively
engage and collaborate with the individual, his/her supports, and the clinical team to establish
the least restrictive course of action(s) for ensuring his/her safety and well-being. 2) This
initiative encourages a system-wide culture shift embracing the beliefs that even one suicide is
too many and that suicide does not have to be an expected consequence of mental illness. 3)
With this training and a change in mindset, behavioral health staff will no longer be helpless in
engaging suicidal individuals and will be empowered to assist in reducing stigma around suicide
within our provider community and the members we serve. 4) With a well-trained clinical
workforce and evidence-based clinical support tools, the ultimate goal is to drive suicide rates
to zero across the Maricopa County Regional Behavioral Health Authority (RBHA). Arizona
Department of Health Services (ADHS), the RBHA and community providers are committed to
this initiative for the individuals we serve. Processes are being implemented across Seriously
Mentally Ill (SMI), General Mental Health/Substance Abuse (GMH/SA), and Child/Adolescent
(C/A) systems to achieve the goal of reaching zero suicides.
Background
A Suicide Prevention and Intervention Committee was developed in October of 2011 to
gather information on current practices in the Title 19/Non-Title 19 SMI population, GMH/SA
population, and Children’s Qualified Services Providers (QSP). Providers representing all of
these populations came together in this committee as a collaborative effort to improve the
current system’s approach to suicide prevention.
The committee researched the Henry Ford Health Care System’s “Perfect Depression
Care” as evidence that reaching zero suicides within a system is possible. Because of this,
“Perfect Depression Care” has been recognized as an innovative program. Within four years,
the suicide rate for their patients had decreased by 75 percent. They more recently reported
ten straight quarters without a suicide death for those enrolled in the Health Maintenance
Organization (Suicide Care in Systems Framework, 2011).

8
In addition to the Henry Ford Health Care System, the committee gathered information
from screens, assessments, and interventions from various sources. These sources included the
Harvard Medical School Guide to Suicide Assessment and Intervention (2007); Suicide Care in
Systems Framework recommendations (2011); Columbia Suicide and Severity Rating Scale (C-
SSRS); Thomas Joiner’s Why People Die by Suicide (2007), as well as the RBHA provider network.
Meeting weekly, the Suicide Prevention and Intervention Committee reviewed best practices
and developed Behavioral Health Screens, Suicide Risk Assessments, and recommended Clinical
Decision Support Tools.

9
*Taken from National Council Magazine, 2012, Issue 2

10
*Taken from National Council Magazine, 2012, Issue 2

11
Pilot Program Summary
A pilot program was implemented from June through August 2012. During the pilot,
sites from the Provider Network Organizations (PNO), GMH/SA providers, and
Children/Adolescent providers utilized the screens, risk assessments, and interventions created
by the workgroup. Over 4,800 screens were administered at the sites, yielding a 16% rate of
positive screens. No suicides were reported from the pilot project. The screens, risk
assessments, and interventions used for those at risk for suicide have undergone continual
review during bi-weekly meetings with the field test providers. We discussed processes,
barriers, and solutions for improvement in order to reach the goal of zero suicides for the
people we serve.
Implementation of the Driving Suicides To Zero (DSTZ) initiative throughout the SMI,
GMH/SA, and Child/Adolescent populations will be completed in 2013.
This manual is a reference guide for clinicians to understand and implement the tools
created. Clinical judgment supersedes process. Therefore, utilize clinical need and professional
judgment as you intervene for any behavioral health individual.
Five components of care will be mapped out throughout this introductory manual:
1) Screening
2) Assessing and stratifying for suicide risk
3) Ensuring safety
4) Intervening for persons at-risk of suicide
5) Following up

12
Behavioral Health Screens
The Suicide Intervention and Prevention Committee reviewed best practice standards
and developed three brief yet informative one-page suicide risk screening tools to be used in
one of the three different clinical populations; adult, adolescent, and children. The baseline for
the risk screen was adapted from Harvard Medical School Guide to Suicide Assessment and
Intervention (2007) and Henry Ford Health System (2001).
Adult Behavioral Health Screen
This three question screen will be self-administered or completed by clinic staff with the
adult behavioral health recipient prior to every clinical or medical appointment. At clinics it was
determined that when the screen was administered by staff there was a reduction in the
misinterpretation of questions. Each site will determine the process they will use to distribute,
score, and disseminate the results, taking available resources and other practical or clinical
concerns into account. For example, for those recipients who are considered chronically
suicidal, each site can implement a special plan or protocol to assist the individual. If the team
determines that repeated exposure to the screen and assessment are counter-therapeutic, they
may consider creating a special plan or protocol to otherwise engage the individual. The focus
for this population should be on individualized interventions, while taking into account the fact
that this population is at high risk for dying by suicide. If there are multiple appointments
during the week, the screen will only need to be given once that week or more if clinically
indicated. The completed screen will be scored by clinic staff, except for those sites where the
screen will be stored and scored electronically.
Scoring Guidelines for the Adult Behavioral Health Screen:
• Affirmation of A3 is a positive screen; or
• Affirmation of B1, or B2, or B3 is a positive screen; or
• Affirmation of A2 plus C2 or C3 is a positive screen

13
Name ____________________________________
DOB _____________________________________
Female Male
Today’s Date _________/___________/_________
Adult Behavioral Health Screen
Your well-being and safety is our priority. In order to assist you today, we would like to know
how you feel right now. Please complete the following three questions and bring to your
appointment today.
A. It is a fact that nearly everyone has, at some time, felt hopeless.
Please circle the number below (0, 1, 2, or 3) that best describes how you feel TODAY
0 I have a positive view of my future
1 I feel uncertain about the future
2 I feel I have nothing to look forward to
3 I feel that the future is hopeless and that things cannot improve
B. It is also a fact that many people have had thoughts of ending their lives.
0 I do not have any thoughts of killing myself
1 I have thoughts of killing myself, but I would not carry them out
2 I would like to kill myself
3 I will kill myself if I have the chance
C. Sometimes using drugs and/or alcohol affect how people think and feel.
Please circle the number below (0, 1, 2, or 3) that best describes if your alcohol or drug use has increased
or changed in the LAST TWO WEEKS
0 I have not used drugs or alcohol
1 I have not increased drugs or alcohol use
2 I have increased drug use or alcohol use more days than not
3 I have increased drugs or alcohol use every day
For Office Use Only: Clinic ___________________ Screening Score ____________________
Current Level of Care: SMI GMH Non Titled ACT Connective Supportive
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999, Henry Ford Health
System, 2009. “Copyright 2011 Magellan Health Services of Arizona, Inc.”

14
Nombre ____________________________________
Fecha de Nacimiento____________________________
Femenino Masculino
Fecha de Hoy _________/___________/_________
Escaneo de Salud Mental para Adultos
Su bienestar y seguridad es nuestra prioridad. Para poder asistirle el día de hoy, nos
gustaría saber cómo se siente usted en este momento. Por favor llene las siguientes tres
preguntas y tráigalas a su cita del día de hoy.
A. Es un hecho que casi todos se han, en algún momento, sentido desanimados.
Por favor encierre en un círculo el número de abajo (0, 1, 2, o 3) que mejor describa como se siente
usted EL DIA DE HOY
0 Yo tengo una imagen positiva de mi futuro
1 Yo me siento incierto sobre el futuro
2 Yo siento que no tengo nada por anhelar
3 Yo siento que el futuro no tiene esperanza y que las cosas no pueden mejorar
B. También es un hecho que muchas personas han tenido pensamientos de terminar con sus vidas.
Por favor circule el número de abajo (0, 1, 2, o 3) que mejor describa como se siente usted EL DIA
DE HOY
0 Yo no tengo pensamientos de matarme
1 Yo tengo pensamientos de matarme, pero no los llevaré a cabo
2 Me gustaría matarme
3 Yo me mataría si tuviera la oportunidad
C. A veces el usar drogas y/o alcohol impacta como las personas piensan y sienten.
Por favor encierre en un círculo el número de abajo (0, 1, 2, o 3) que mejor describa su consumo de
alcohol o drogas en las dos últimas semanas
0 Yo no he consumido drogas o alcohol
1 Yo no he incrementado el uso de drogas o alcohol
2 Yo he aumentado el uso drogas o alcohol la mayoría de los días
3 Yo he aumentado el uso de drogas o alcohol todos los días
For Office Use Only: Clinic ___________________ Screening Score ____________________
Current Level of Care: SMI GMH Non Titled ACT Connective Supportive
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999, Henry Ford Health
System, 2009. “Copyright 2011 Magellan Health Services of Arizona, Inc.”

15
Adolescent Behavioral Health Screen
This three question screen will be self-administered or completed by clinic staff with the
adolescent (ages 13-17) prior to every clinical or medical appointment. Each site will determine
the process they will use to distribute, score, and disseminate the results, taking available
resources and other practical or clinical concerns into account. If there are multiple
appointments during the week, the screen will only need to be given once that week or more
as clinically indicated. The completed screen will be scored by clinical staff.
Scoring Guidelines for the Adolescent Behavioral Health Screen:
• Affirmation B1, or B2, or B3 is a positive screen; or
• Affirmation of A2 plus C2 or C3 is a positive screen

16
Name ____________________________________
DOB _____________________________________
Female Male
Today’s Date _________/___________/_________
Adolescent Behavioral Health Screen (13-17)
Your well-being and safety is important to us. In order to help you today, we would like to know
how you are feeling right now. Please complete the following three questions. Bring this to
today’s appointment.
A. People feel hopeless sometimes:
0 I do feel positive about the future
1 I feel uncertain about the future
2 I feel I have nothing to look forward to
3 I feel that the future is hopeless and that things cannot improve
B. Many people have had thoughts of ending their lives:
Please circle the number below (0, 1, 2, or 3) that best describes how you feel RIGHT NOW
0 I do not have any thoughts of killing myself
1 I have thoughts of killing myself, but I would not carry them out
2 I would like to kill myself
3 I will kill myself if I have the chance
C. Many people know someone who has killed him or herself or who is talking about doing it:
Please circle the number below (0, 1, 2, or 3) that best describes your situation
0 I do not know anyone who has done that
1 I know of someone who did that but he/she was not close to me
2 I have a friend or family member who is talking about wanting to kill him or herself
3 My friend or family member recently killed him or herself
For Office Use Only:
Clinic ________________ Screening Score _____________ Staff Name ________________________
Current Level of Services: High Needs Case Management Clinical Services Support Services
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999, Henry Ford Health System,
2009. “Copyright 2011 Magellan Health Services of Arizona, Inc.”

17
Nombre ____________________________________
Fecha de Nacimiento__________________________
Femenino Masculino
Fecha de Hoy ________/___________/_________
Escaneo de Salud Mental para Jóvenes (13-17)
Tu bienestar y seguridad es muy importante para nosotros. Para poder
ayudarte el día de hoy, nos gustaría saber cómo te sientes en este momento. Por
favor llena las siguientes tres preguntas. Tráelas a tu cita de hoy.
A. Las personas se sienten desanimadas a veces:
Por favor encierra en un círculo el número de abajo (0, 1, 2, o 3) que mejor describa cómo te
sientes tú EL DIA DE HOY
0 Yo me siento positivo sobre el futuro
1 Yo me siento incierto sobre el futuro
2 Yo siento que no tengo nada por anhelar
3 Yo siento que el futuro no tiene esperanza y que las cosas no pueden mejorar
B. Muchas personas han tenido pensamientos de terminar con sus vidas:
Por favor encierra en un círculo el número de abajo (0, 1, 2, o 3) que mejor describa cómo te
sientes tú EN ESTE MOMENTO
0 Yo no tengo pensamientos de matarme
1 Yo tengo pensamientos de matarme, pero no los llevaré a cabo
3 Yo me mataría si tuviera la oportunidad
C. Muchas personas conocen a alguien que se ha suicidado o que está hablando de hacerlo:
Por favor encierra en un círculo el número de abajo (0, 1, 2, o 3) que mejor describa tu situación
0 Yo no conozco a nadie que haya hecho eso
1 Yo conozco a alguien quien hizo eso pero él/ella no era cercano(a) a mi
2 Tengo un amigo(a) o un miembro de mi familia quien está hablando de quererse matar
3 Mi amigo(a) o miembro de familia recientemente se suicidó
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999, Henry Ford
Health System, 2009. “Copyright 2011 Magellan Health Services of Arizona, Inc.”

18
Children’s Behavioral Health Screen
This two question screening tool will be completed by the clinician with a child age 10-
12 (or younger if clinically indicated), prior to every clinical or medical appointment. This screen
will be given no more than once a week and can be administered by a trained, licensed or non-
licensed individual. The form is not meant to be prescriptive, in that the provider does not have
to read the screen word for word. Rather, the questions and concepts can be incorporated in
the provider’s day to day interactions and dialogue with the child. From that conversation, the
provider should be able to extract the appropriate information from the child and score the
screen accordingly. If there are multiple appointments during the week, the screen will only
need to be given once that week or more as clinically indicated.
Communication with Family/Guardian
Some families/guardians may feel uncomfortable when their child is asked about
suicidal thoughts. Therefore, it is recommended that clinicians choose supportive, non-
threatening terminology. Informing them that this dialogue will help formulate a treatment
plan and address immediate needs can alleviate possible discomfort, particularly around
suicide. Providers are encouraged to train staff to have clinically appropriate, culturally
sensitive conversations with family members/guardians about childhood suicide. Staff should
follow their agency’s protocol for family education regarding suicide prevention.
Scoring Guidelines for the Children’s Behavioral Health Screen:
• Affirmation of B1,or B2, or B3 is a positive screen

19
Name ____________________________________
DOB _____________________________________
Female Male
Today’s Date _________/___________/_________
Children’s Behavioral Health Screen
Completed by a clinician for ages 10 to 12 (younger, as clinically appropriate)
Your well-being and safety is very important to us. In order to help you today in your
appointment, we would like to know how you feel right now.
A. Most kids worry sometimes about growing up:
With the following choices (0, 1, 2, or 3) please let me know how you feel RIGHT NOW
0 I am excited about growing up
1 I worry about what it will be like to grow up
2 Hardly anything I do makes me feel happy
3 I can’t picture myself grown up
B. Some kids have had thoughts about dying or killing themselves:
With the following choices (0, 1, 2, or 3) please let me know how you feel RIGHT NOW
0 I don’t have any thoughts of killing myself
1 I wish I were dead, or have thoughts of killing myself, but I would not do it
2 I’d like to kill myself
3 I’d kill myself if I could
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999.
“Copyright 2011 Magellan Health Services of Arizona, Inc.”

20
Nombre ____________________________________
Fecha de Nacimiento _________________________
Femenino Masculino
Fecha de Hoy _________/___________/_________
Escaneo de Salud Mental para Niños
Llenado por un profesional clínico para edades de 6 – 12 (y más jóvenes si es apropiado)
Tu bienestar y seguridad es muy importante para nosotros. Para poder ayudarte
el día de hoy en tu cita, nos gustaría saber cómo te sientes en este momento.
A. La mayoría de niños a veces se preocupan sobre el crecimiento:
Con las siguientes opciones (0, 1, 2, o 3) por favor déjame saber cómo te sientes tú EN ESTE
MOMENTO
0 Estoy entusiasmado sobre el crecimiento
1 Me preocupa cómo será crecer
2 Casi nada de lo que hago me hace sentir feliz
3 No puedo imaginarme como adulto
B. Algunos niños han tenido pensamientos de muerte o de matarse:
Con las siguientes opciones (0, 1, 2, o 3) por favor déjame saber cómo te sientes tú EN ESTE
MOMENTO
0 No tengo ningún pensamiento de matarme
1 Deseo estar muerto, o tengo pensamientos de matarme, pero no lo haría
3 Me mataría si pudiera
*Adapted from The Harvard Medical School Guide to Suicide Assessment and Intervention, Douglas Jacobs(Ed), Jossey-Bass, 1999.
“Copyright 2011 Magellan Health Services of Arizona, Inc.”

21
Suicide Risk Assessment
Any adult whose screen is positive should be formally assessed by a licensed clinician,
Nurse, or Behavioral Health Medical Provider (BHMP) using the suicide risk assessment tool in
order to review suicide intent, desire, and capability. A trained, licensed or non-licensed staff
can complete the risk assessment tool for children and adolescents. Any person whose screen
is negative for possible suicide risk should be treated as clinically indicated.
The suicide risk assessment was adopted from combining recommendations from the
multidisciplinary Suicide Prevention and Intervention Committee, Henry Ford Health
Assessment (2001); Community Bridges Risk Assessment; Connections of Arizona Risk
Assessment; Thomas Joiner’s Why People Die by Suicide (2007); and the Columbia Suicide and
Severity Rating Scale (C-SSRS). This assessment is intended to be administered by any licensed
clinician possessing skills to engage the person receiving services. The professional should have
specific training in assessing and evaluating risk.
Suicidal desire, capability, and intent are the core principles from Thomas Joiner’s
theory of suicidal behavior. A combination of all three would assert that the person is at acute
risk for suicide. Protective Factors, which are listed on the assessment, should also be
considered.

24
Suicide Risk Assessment Definitions
The following definitions have been given to some of the elements listed in the Suicide
Risk Assessment. Please refer to the DSM-IV-TR for any definitions relating to diagnoses.
Acute Risk Factors
Access to firearms/lethal means – Identify if there are weapons in the home and whether the
person has the ability to access and use a firearm. If there is accessibility please follow the
weapon safety suggestions listed on page 37.
Intolerable chronic pain – Poorly managed or unmanaged pain that is perceived as intolerable
that could result in suicidal thoughts.
Loss and trauma (current) – May include but it is not limited to, sexual abuse, physical abuse,
emotional abuse, death, loss, and bullying. The loss/trauma is negatively impacting the
individual’s functioning and/or emotional well-being.
Recent alcohol/drug use – Increase in use, frequency, and/or introduction to a new drug could
be interpreted as a risk factor. In general, “recent” refers to patterns within the last two weeks.
Severe anhedonia – Person is unable to find joy in activities that were once pleasurable.
Suicidal capability – Relates to imminent plans and fearlessness about suicidality. Suicidal
capability is comprised of the following: a sense of fearlessness and/or competence to make an
attempt, availability of means leading to opportunities for attempts, specificity of plan, and/or
preparations for attempt.1
Suicidal desire – No reason for living, a wish to die, a wish to not carry on, suicidal thoughts,
and/or not caring if death occurs. Some strong contributors to suicidal desire are feelings of
hopelessness, feeling trapped, feeling that there is no alternative course of action, feeling
intolerably alone, intense psychological pain, helplessness, and perceiving oneself as a burden
to others.1
Suicidal intent – Comprised of a current plan to hurt oneself, preparatory behavior, and
expressed intent to die.1
Social isolation – Person is isolating from the outside world and/or is refusing to leave the
house or participate in any activities. This could include missing multiple days of work/school
or lack of contact with family members/friends.
Suicide Plan – Plan can include a multitude of lethal means for suicide. Assess for these means
and the accessibility to them. According to the National Institute of Mental Health, “young
people were more likely to use firearms, suffocation, and poisoning than other methods of
suicide, overall. Adolescents and young adults are more likely to use firearms than suffocation;
children were dramatically more likely to use suffocation.”2
1
Thomas Joiner, 2007;
2
nimh.nih.gov

25
Victim of Bullying – Bullying is the use of coercion or force to abuse or intimidate others. The behavior
can be habitual and usually involves a disparity of social or physical power. It can include physical
assault or coercion, verbal harassment or threat, and may be directed repeatedly toward particular
victims.
Moderate Risk Factors
Co-occurring Disorder – Refer to DSM-IV -TR; Axis I psychiatric disorder plus a substance use
diagnosis, or personality disorder.
Events leading to despair or humiliation – For the Child/Adolescent population, this could
include peer pressure, bullying or being bullied.
Family/friend history of suicidal behavior – This could include suicide completion by any family
or friend that is impacting current functioning or emotional wellbeing.
Perceived burden to others – The person believes life would be better/easier for others if he or
she was not alive. It is defined as the intensity with which the person believes he or she is a
burden to others.
Social withdrawal – Decline in social interactions, lack of contact with people and/or would
prefer to be alone.
Protective/Risk Factors
Adult demographic chronic risk factors –These factors should not determine suicide risk level
for an individual, however, they should be considered when assessing someone for suicidal risk.
Adult protective factors – Buffers/Connectedness for adults include immediate supports, social
supports, planning for the future, positive therapeutic relationships, ambivalence for dying,
core values and beliefs, and sense of purpose.
Child/Adolescent protective factors – Include supervision by parents, good support system,
attendance in school, engagement in treatment, medication compliance, and close
relationships.

26
Clinical Decision Support Tools
The interventions identified in the Clinical Decision Support Tools were initially
influenced by the Henry Ford Healthcare System. The committee compiled current best
practices utilized in everyday operations and identified additional interventions to assist in the
goal of driving suicide rates to zero within each population. Emphasis has been placed on active
engagement, continuity of care, weapon identification, family and peer involvement (formal
and non-formal), and follow up processes.
“Active engagement proceeds from the understanding that the most effective course
for interacting with anyone seeking help or comfort is to support their personal needs, wishes
and values, as they relate to the individual’s best self-interests” (Draper et al., 2010). The active
engagement approach takes into account the individual’s experience and resources; builds
hope for recovery; and empowers individuals to resolve crises and long-term problems utilizing
less invasive interventions. Active engagement includes non-judgment mirroring and
summarizing statements as well as asking clarifying questions. This illustrates the genuine
intention to understand the individual’s feelings and builds the framework for a strong
therapeutic alliance. The result of active engagement is the individual feeling heard, cared for,
and empowered to make safe decisions.
Suggested clinical decision support tools will be in place for all three risk levels for each
population, based on the population’s resources. These suggested guidelines do not fall into
any particular order, and are not limited to these recommendations. Clinical judgment
supersedes the process and/or timeframes suggested.
**Ask a supervisor for guidance if at any time there is a question about services needed to keep the
individual safe**
Clinical Decision Support Tool Definitions
• ARCP – At Risk Crisis Plan - A proactive plan developed with the recipient for the clinical team,
Crisis Response Network, and other providers to provide interventions and supports the
recipient and clinical team have identified as being the most helpful in addressing increased
symptoms.
• AUD/ROI – Authorized Use of Disclosure/Release of Information – Information sharing.
• ACCESS AND TRANSITION POINT (APTP) - A front door to the behavioral health system offering
assessment for ongoing services, brief intervention, and coordination of care through
contracted network providers.
o 24/7 Access to Care Line: 877-931-9142
o Website: Communitybridgesaz.org
West Valley East Valley
824 N. 99
th
Ave 358 E. Javelina Avenue #101
Avondale, AZ 85323 Mesa, AZ 85323

27
• BHMP – Behavioral Health Medical Professional - Supervises staff delivery of direct clinical
services, monitors recipient’s clinical status. May be a Psychiatrist, Physicians Assistant, or a
Nurse Practitioner.
• BHP – Behavioral Health Professional – Licensed Professional.
• CFT – Child and Family Team – Defined group of people including child, family, behavioral health
representatives and anyone important in the child’s life.
• PEER SUPPORT ATTEMPT SURVIVOR GROUP - Peer run groups which will provide those
members who have attempted suicide with support and hope.
• QSP – Qualified Service Provider – Providers who contract with the Children’s Provider Network
Organizations

32
Same Day Interventions for Low, Moderate, and Acute risk level across All Populations
*Utilize clinical need and professional judgment as you go through the process map.
Good clinical judgment supersedes the process and/or timeframe listed above.
• Acute Risk Individuals in any population need to be seen the same day by the BHMP. If
a BHMP is not available on site, contact the Medical Director to staff and determine
what is required in order for the individual to be seen on the same day. The acute risk
individual could be seen at another clinic. After the visit with the BHMP, a follow up
appointment within 2 weeks is suggested.
• The level of risk determined by a BHP should be staffed with a BHMP to confirm level of
risk and response.
• If recipient is acute, arrange for all necessary services before that person leaves the
clinic. This should include community resources, family, peer support, and any other
agreed upon interventions. Due to hospitalization being a critical event in the person’s
life, hospitalization should be used as a last resort.
• A follow up appointment with the BHMP for any level of risk should be made within 2
weeks of initial risk assessment.
• Run the recipient’s name through the pharmacy database, as clinically indicated. This is
run for recipients suspected of drug abuse, who have a history of medication overdose,
or questionable medication adherence. Do not put this information in the recipient’s
medical record as it does have other medical provider information listed.
• Gather contact information from recipient/caregiver.
• Initiate a support plan; obtain AUD’s/ROI’s for individuals named in the support plan. A
support plan can include friends and family as well as other caregivers. Identify anyone
that is a support to the recipient and can be available during the risk period.
• Create a safety plan – identify immediate future plans regarding activities in which the
recipient is going to be involved. Plan should be created for potential crisis situations.
Connect with the support individuals while recipient is in the room so all parties are
aware of the plan.
o T19 SMI population – Review the ARCP and make any changes that are needed.
Consider informing after-hour crisis staff of safety plan.
• All parties involved should be given a list of emergency phone numbers.
• Identify if weapons are in the home. If weapons are available and accessible, advise to
remove weapons and follow weapon safety suggestions on page 37. Encourage
family/support individual to identify potential lethal means such as prescriptions and
over the counter medications. The goal is to attempt to limit access to any type of
means.
o Though it may be difficult to remove all lethal means from a home, a home
safety inventory can be discussed with the recipient and/or support person as
well as the guardian/parents.

33
• Utilize crisis services, if after hours.
• Needs assessment for outpatient services – Review current services in which the
individual is involved. Review any services the recipient may utilize in the future to assist
with stressors.
• Contact existing providers within and outside of the clinic to inform of risk level. There
are multiple formal supports that could be involved in the recipient’s life, including
people within the agency. It is best practice to collaborate with these individuals to
inform them of the risk level and interventions/safety plan that are going to be
implemented.
Next Day Interventions for Low, Moderate, and Acute risk level across All Populations
• Contact should be made with the recipient. If no contact is made with the recipient the
following day, reach out to support individuals, emergency contacts, or crisis. Follow
outreach protocol as clinically indicated.
o T19 SMI Adults – It is suggested that a face to face visit is to be conducted in the
clinic or in the home.
 It is recommended at moderate and acute risk levels that a home visit is
completed to observe the environment.
o NT19 SMI Adults – Telephone call to recipient.
 At acute risk levels – Mobile team telephonic check-ups for follow up can
be requested.
o GMH/SA – It is suggested that the recipient come into the clinic or that outreach
be done by telephone.
o Child/Adolescent – Follow up telephone contact or face to face visit in the home
or in the clinic.
• Coordinate with individuals named in the support plan to provide ongoing assistance
and gather information regarding recipient’s behavior or any change in his/her risk level.
o Child/Adolescent – It is suggested that the CFT be engaged as described in the
Clinical Decision Support Tool. CFT meetings do not have to happen in a face to
face interaction and can be held via conference call. Interventions can be
initiated prior to holding a CFT meeting.
o At acute risk level – Conduct emergence CFT and monitor until no longer at risk.
o At moderate risk level – The CFT should be engaged within 5 days.
o At low risk level – The CFT should be engaged within 7 days.
• Offer peer and family mentors, if available. These mentors can be extremely helpful in
engaging the recipient and maintaining contact with individuals named in support plan.
• At acute risk level, it is recommended that referrals to outside service providers for
future support take place.
• Ongoing communication within the clinic.
o T19 SMI – Discuss recipient in morning meeting each day until no longer at risk.

34
o GMH/SA – Ongoing communication with staff members within the agency with
whom the recipient is involved.
o Child/Adolescent – Ongoing communication with staff members within the
agency with whom the recipient is involved.
Within 48 hours for Moderate and High Risk Level for All Populations
• Telephonic follow up or face to face visit, based on clinical need.
• Coordination with individuals listed in support plan.
• Referrals to outside service providers for future support.
• Send a “Caring Letter”, text, or email. Research has shown a caring letter, text, or email
sent out to the recipient (or caregiver addressed to the recipient) has shown positive
results in engaging the individual in treatment and decreases the thought processes for
suicide. The “Caring Letter” includes kind and caring words from the clinical team to let
the recipient know others are thinking about him/her and appreciate him/her. A text or
a letter format is recommended because people may not open email for a couple of
weeks.
Within 48 hours for Low Risk Level for All Populations
• Telephonic follow up or face to face visit, based on clinical need.
• Coordination with individuals listed in the support plan.
• Referrals to outside service providers for future support.
Follow up for All Populations
• Screen at next appointment.
• Continue to reassess risk with recipient until Behavioral Health Screen no longer yields a
positive result.
• Ongoing contact with recipient, based on clinical need.
• Ongoing contact with individuals listed on support plan, based on clinical need.
• Continual engagement with the individual is highly recommended in order to keep the
individual connected to the community. Many resources and opportunities to get
involved are listed on the Magellan of Arizona Website: magellanofaz.com. A few of the
links are listed below:
o Community Exchange: http://magellanofaz.com/mypage-en/get-
involved/community-exchange.aspx
o Family Engagement: http://magellanofaz.com/mypage-en/get-involved/role-of-
family-members.aspx
o Provider Directories: http://magellanofaz.com/mypage-en/find-a-
provider/provider--clinic-directories.aspx

35
Other Interventions
Intervention recommendations are based on available resources; however, we encourage
clinicians to customize any interventions that would be helpful for each individual. Thus, the
options listed in the clinical decision support tools are simply options to be considered and are
not conclusive of all possible interventions. Due to hospitalization being a critical event in the
person’s life, hospitalization should be used as a last resort. Other interventions that were
gathered from the pilot project include, but are not limited to the following items:
Title 19
• Well check over the weekend: The Clinical Coordinator (CC) calls the recipient and if no
answer, Crisis should be sent out to do a well check.
• The RN or Therapist can see the recipient in place of the BHMP if there is limited BHMP
availability.
• Discuss those recipients at risk in morning meeting.
• Recipients are given medication bubble packs which can be provided daily or weekly.
This limits access to large quantities of medications. Some recipients may be asked to
come to the clinic daily for their medication.
• Referrals can be made to a day program.
• Referrals can be made to Peer Support Groups.
Non-Title 19
• Over the weekend, a well check can be set up with Crisis.
• Check third party payers for resources when needed.
• Recipients are given medication bubble packs which can be provided daily or weekly.
This limits access to large quantities of medications. Some recipients may be asked to
come to the clinic daily for their medication.
• The RN can see the recipient in place of the BHMP if there is limited BHMP availability.
• Discuss those recipients at risk in morning meeting.

36
Imminent Risk
• Imminent Risk is “a close temporal connection between the person’s current risk status
and actions that could lead to his/her suicide. The risk must be present in the sense that
it creates an obligation and immediate pressure on staff to take urgent actions to
reduce the individual’s risk; that is, if no actions were taken, the staff believes that the
individual would be likely to seriously harm or kill him/her self. 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 or carrying
through his/her intent” (Draper et al., 2010). Clinical judgment and discussion with
leadership is important in order to determine appropriate interventions.
• When an individual is determined to be at imminent risk, staff should follow internal
provider policies to initiate any and all measures necessary to ensure the individual’s
safety. This may include calling Crisis Response Network, law enforcement, and/or
supports identified in the At Risk Crisis Plan.

37
Weapon Safety Suggestions
Upon identifying that weapons are in the home, the following steps are suggestions:
1. Follow your company’s policy as it relates to weapon safety.
2. During the Suicide Risk Assessment, if weapons are identified:
• Have recipient sign a release form naming the support person(s).
• Have recipient/guardian identify the support person with correct phone number(s) and
address(s).
• Obtain recipient/guardian agreement to identify all weapons and agree to their
removal.
• Guardians/caregivers should be contacted.
3. Establish an individual safety plan for the weapon removal.
• Contact support person with recipient in the room to implement plan for weapons
removal. This is especially important if the recipient is an adolescent or a child. If
parents/roommates own a weapon, coordinate with them to lock in a secured place,
giving the recipient no access.
• If the support person needs assistance and the individual is agreeable to removal, police
may be called to assist with weapon removal from the home. *
• Police cannot force recipient to release weapon if the individual refuses.
• After the crisis has been resolved, return of weapons or ammunition to the home is not
recommended.
• Bringing the weapons to the clinic or the hospital is prohibited.
• If weapons are identified during a home visit, clinical staff should always secure their
own safety. If there is imminent risk, police should be called. *
• If the person is currently or has previously been on Court Ordered Treatment, it is a
felony to own a firearm. For your information, if the police are called in this
circumstance, the person could be arrested.
*If it is decided that police should be called, be able to articulate your need for police
presence. There should be a definable safety issue and/or need to secure a weapon.
*Be familiar with your local police department protocol for weapon safety.

38
Contributors
CHOICES Network
Community Bridges
Connections of Arizona
Crisis Response Network
EMPACT
Hope Lives
Jewish and Family Children’s Services
Lifewell Behavioral Wellness
Partners In Recovery
People Of Color Network
Phoenix Police Department
Recovery Innovations of Arizona
Southwest Behavioral Health
Southwest Network
TERROS
Touchstone Behavioral Health
Valle del Sol
Karen Chaney - Magellan Health Services
David Covington – Magellan Health Services
Shareh Ghani - Magellan Health Services
Erica Goble - Magellan Health Services
Christine Ketchmark - Magellan Health Services
Lois McLean - Magellan Health Services
Gowri Shetty - Magellan Health Services
Roni Siebels - Magellan Health Services

39
References
Draper, J., Mishara, B., Covington, D., Vega, E. Lee, J., Anderson, C….McKeon, R. (2010).
Establishing Policies and Guidelines for Helping National Suicide Prevention Lifeline
Callers at Imminent Risk of Suicide: Research and Rationale.
Joiner, T, (2005). Why People Die by Suicide. Cambridge, MA: Harvard University Press.
Magellan of Arizona. (2013). Suicide Prevention. Retrieved from
http://magellanofaz.com/programs/suicide-prevention.aspx.
National Institute of Mental Health. (2013). Suicide in the U.S.: Statistics and Prevention.
Retrieved from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-
and-prevention/index.shtml.
Suicide Prevention: Not another life to lose. (2012, Issue 2). National Council Magazine, 15, 33.

40
Contacts
Karen Corallo Chaney, MD
Adult Medical Director
Magellan Health Services
4801 E. Washington
Phoenix, AZ 85034
602.572.5830
KCChaney@magellanhealth.com
Erica Goble, MBA
Child & Youth Services Liaison
4801 E. Washington
Phoenix, AZ 85034
602.572.5840
EMGoble@magellanhealth.com
Christine Ketchmark, Psy.D.
Director of Clinical Analytics, Outcomes, and Integration
4801 E. Washington
Phoenix, AZ 85034
602.572.8319
CKetchmark@magellanhealth.com
For Training Purposes:
Shanna Galdys
Learning Manager
4801 E. Washington
Phoenix, AZ 85034
602.797.8203
SMGaldys@magellanhealth.com

Magellan Health’s Programmatic Suicide Deterrent System

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (16)

Similar to Magellan Health’s Programmatic Suicide Deterrent System

Similar to Magellan Health’s Programmatic Suicide Deterrent System (20)

More from David Covington

More from David Covington (20)

Recently uploaded

Recently uploaded (20)

Magellan Health’s Programmatic Suicide Deterrent System