» Table of Contents

Improving Uptake of the VA Suicide Risk Identification Strategy

Takeaway: This QUERI partnered evaluation project both tailors and adapts quality improvement strategies in order to advance implementation of population-based suicide risk screening and evaluation across the VA healthcare system.

According to the 2019 National Veteran Suicide Prevention Annual Report, the number of Veterans who died by suicide exceeded 6,000 per year between 2008 to 2017. Emerging evidence indicates that many individuals who die by suicide are not identified as having psychiatric disorders, and often present for non-behavioral healthcare prior to their death. Current research suggests that early and accurate detection of suicide risk among all Veterans presenting for VA care is a critical component of reducing suicide rates among Veterans. In October 2018, VA developed a system-wide, multi-staged strategy for standardized, evidence-based screening of suicide risk, and structured methods for the subsequent evaluation of those who screen positive for suicide risk (VA Risk ID). VA Risk ID is the largest implementation of population-based suicide risk screening and evaluation in any United States healthcare system to date.

Ongoing evaluation of VA Risk ID as well as interventions to improve the implementation of the staged screening and evaluation process are needed in order to facilitate continuous quality improvement. Working with VA’s Office of Mental Health and Suicide Prevention, the Examining the Effectiveness of an Adaptive Implementation Intervention to Improve Uptake of the VA Suicide Risk Identification Strategy QUERI Partnered Evaluation Initiative aims to develop an adaptive implementation strategy to improve the implementation of Risk ID among patients receiving care in ambulatory care settings.

The focus on an adaptive implementation strategy provides an opportunity to vary the level and type of implementation support provided to VA healthcare facilities based on performance. This is important because facilities will differ with respect to VA Risk ID uptake and implementation barriers. Using a sequential, multiple-assignment randomized trial (SMART), this project will evaluate the effectiveness of two evidence-based implementation strategies (Figure 1) across three phases.

The run-in phase will begin with implementation as usual. During this phase, all facilities will have access to resources provided through the Risk ID program (e.g., education & training, technical assistance). In phases one and two – 1) Audit and Feedback (A/F), and 2) Audit and Feedback plus External Facilitation (A/F+EF) – facilities facing challenges in meeting implementation adherence goals will receive a sequence of implementation boosters. Investigators will evaluate the impact of these strategies on changes in VA Risk ID performance over time. In addition, QUERI investigators will examine whether uptake of VA Risk ID contributes to greater use of other suicide risk management practices, such as safety planning.

This project is expected to help VA healthcare facilities address implementation challenges related to VA Risk ID. The goal is to ensure that more Veterans are screened and evaluated for suicide risk, which is the basis of effective, patient-centered suicide risk management. Moreover, since the implementation intervention “dose” is determined by monitoring facility performance over time, the project allows for individualized resource deployment, with the program office determining when and where resources are most needed.

For more information about this QUERI Partnered Evaluation, please contact Nazanin Bahraini, PhD, at Nazanin.Bahraini@va.gov .