Telehealth to Improve Prevention of Suicide (TIPS) in EDs

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ABSTRACT Significance: Our study will rigorously evaluate whether synchronous, within-visit telemental health evaluation and intervention services can successfully overcome poor access to behavioral health and substandard suicide-related care in emergency departments (EDs), including evaluating the impact on system metrics, a primary goal of RFA-MH-20-226. Notably, our study will surpass this primary requirement, because it will extend our understanding of the relative added value of the ED-SAFE post-visit telephone intervention and will create knowledge about key factors related to implementation and sustainment. Investigators: The team has extensive expertise in healthcare systems-based suicide prevention using continuous quality improvement implementation strategies (Boudreaux, Larkin, Miller), telehealth for behavioral health disorders (Boudreaux, Davis-Martin, Brown, Allen), using “big data” for outcome and intervention target ascertainment (Mathew, Liu, Li, Clements), and implementation science (Boudreaux, Larkin, Davis-Martin). Innovation: This will be the first study to evaluate telehealth for suicide prevention in the ED. It will use best- practices in both telemental health and suicide prevention and is designed for rapid dissemination. Our study design, an interrupted time series with a nested RCT and parallel Non-intervention control EDs, embodies cutting edge implementation science methodology. Our analyses are modeled after NIMH's experimental therapeutics paradigm, allowing us to evaluate intervention targets appropriate for healthcare service delivery studies. Approach: We will compare three conditions across two Intervention EDs that currently do not have on-site behavioral health specialists: (1) Treatment as usual (TAU), (2) Telehealth to Improve Prevention of Suicide (TIPS), which will include within-visit telehealth components only, and (3) TIPS+EDSAFE, which will include within- and post-visit components. Aim 1 will evaluate whether TIPS alone improves primary system metrics and suicide-related care practices compared to TAU. Aim 2 will compare 12-month patient outcomes, including a suicide composite outcome, across TAU, TIPS, and TIPS+EDSAFE. Aim 3 will evaluate factors related to implementation and sustainability, including costs. Two Non-intervention EDs will be monitored to control for macro system changes and secular trends. Existing big data sources, augmented by structured chart review, will be leveraged for efficient outcome ascertainment that maximizes sample representativeness. Environment: UMass has demonstrated its ability to support this study by its success with the NIMH-funded System of Safety (SOS) study, a Zero Suicide pragmatic clinical trial, in addition to its successful telehealth efforts funded through NIH and the Commonwealth of Massachusetts. Impact: The TIPS will address numerous fundamental questions around the role of telehealth in suicide prevention in a highly efficient, pragmatic clinical trial, maximizing the study's scientific and public health impact and building a singular database that will serve as an enduring resource to the suicide prevention community.