Rapid Referral to Suicide Specific Intervention in Psychiatric Emergency Care

这项修订后的提案回应了HSR&D针对自杀的卫生服务研究的定向征集 预防。当天的精神科急诊越来越多地得到实施，是 增加获得精神卫生保健和预防自杀的机会。我们的初步数据显示 寻求当天心理健康的退伍军人自杀意念和近期自杀行为的频率 评估，但有这些危险因素的退伍军人中只有不到一半的人从事门诊心理健康 在最初的尖锐评估之后确定的任命。为了减少自杀的风险 从急诊到门诊的过渡，尚不清楚过渡的模型是否应该强调 由自杀预防协调小组提供的电话外展，或针对自杀的心理治疗， 例如自杀行为的协作评估和管理(CAMS)。CAMS是一种简短的跨诊断 循证心理治疗被联合委员会和零自杀框架确认为 适用于有积极自杀意念和/或最近自杀行为的退伍军人。这一单站点4- 一年的随机临床试验解决了关于快速转诊对 CAMS与自杀预防协调员为退伍军人提供的外联服务的比较 访问当天的精神健康评估，并评估谁有更高的自杀风险。在混合体中 类型1研究设计，我们建议招募来自同一天诊所环境的退伍军人，他们最近或 在过去3个月内有自杀念头和/或自杀未遂。退伍军人将被随机分配 及时启动CAMS或通过电话联系自杀预防协调员。初级阶段 结果(目标1)是自杀相关行为或精神病住院的12个月比率。目标2 对比随机条件下的业务效率指标，包括退伍军人比率 错过转诊的预约正在进行的精神健康护理和紧急护理重新提交。我们还将 评估二次结果(例如，自杀意念的严重程度)。目标3将考察以下因素的中介影响 门诊精神卫生治疗参与度对主要结局的影响。AIM 4评估对CAMS的忠诚度和 它与结果的关联。保真度和面对面的结果是通过使用信息来衡量的 一种称为电子筛选的技术，它与电子病历集成在一起，并被快速使用 转诊和基于测量的护理。这个项目建立在我们的初步数据基础上，这些数据表明 在同一天的环境中招募和快速转诊到CAMS治疗是高度可行的、可接受的和 潜在的影响力。该项目的创新之处在于，它在同一天关注过渡性护理干预 诊所设置及其与卫生信息技术的集成，以促进快速转诊，可扩展到 传播其他循证治疗。这项研究直接响应了国家优先考虑的 自杀预防研究议程，强调需要提供针对自杀的护理模式 一旦确定风险就进行干预“，并解决了在及时自杀影响方面的重要差距 预防策略确定了白宫的报告。这项研究也回应了HSR&D的心理和 行为健康、获取和护理协调优先领域。我们希望这些数据能给我们提供最好的信息。 在许多高危退伍军人出现的当天精神卫生服务中预防自杀的做法。

This revised proposal responds to HSR&D's Targeted Solicitation for Health Services Research on Suicide Prevention. Same-day psychiatric emergency clinics are increasingly implemented and are a best practice in increasing access to mental health care and in suicide prevention. Our preliminary data indicate a high frequency of suicidal ideation and recent suicidal behavior among Veterans accessing same-day mental health evaluation, and yet fewer than half of Veterans with these risk factors engage in outpatient mental health appointments that are set following their initial acute evaluation. To reduce risk of suicide during the transition from acute to outpatient care, it is unclear if models that “bridge” the transition should emphasize telephone outreach, as delivered by Suicide Prevention Coordination teams, or suicide-specific psychotherapy, such as Collaborative Assessment and Management of Suicidality (CAMS). CAMS is a brief transdiagnostic evidence-based psychotherapy that is recognized by the Joint Commission and Zero Suicide Framework as indicated for Veterans experiencing active suicidal ideation and/or recent suicidal behavior. This single-site 4- year randomized clinical trial addresses pragmatic questions regarding the relative impact of rapid referral to CAMS versus compared to outreach delivered by Suicide Prevention Coordinators for Veterans who are accessing same day mental health evaluation and who are gauged to be at elevated risk for suicide. In a Hybrid Type 1 research design, we propose to recruit Veterans from the same-day clinic setting who report recent or current active suicidal ideation and/or suicide attempt within the past 3 months. Veterans will be randomized to timely initiation of CAMS or to telephone outreach from Suicide Prevention Coordinators. The primary outcome (Aim 1) is the 12-month rate of suicide-related behavior or psychiatric hospitalization. Aim 2 contrasts indicators of operational efficiency between randomized conditions, including Veterans' rate of missed appointments at referred ongoing mental health care and urgent care re-presentation. We will also evaluate secondary outcomes (e.g., suicidal ideation severity). Aim 3 will examine the mediating impact of outpatient mental health treatment engagement on primary outcomes. Aim 4 evaluates fidelity to CAMS and its association with outcomes. Fidelity and in-person outcomes are measured by use of information technology, called eScreening, that is integrated with the electronic medical record and is used coordinate rapid referral and measurement-based care. This project builds on our preliminary data which indicate that research recruitment and rapid referral to CAMS therapy in same-day setting is highly feasible, acceptable and potentially impactful. This project is innovative in its focus on transitional care interventions in the same day clinic setting and its integration of health information technology to facilitate rapid referral, extensible to the dissemination of other evidence-based treatments. This research directly responds to the National Prioritized Research Agenda for Suicide Prevention, which emphasizes a need for care models that deliver “suicide-specific intervention as soon as risk is identified” and addresses important gaps on the impact of timely suicide prevention strategies identified the White House report. The study also responds to the HSR&D Mental and Behavioral Health, Access, and Care Coordination Priority Areas. We expect that these data will inform best practices in suicide prevention in same day mental health services where many at-risk Veterans are seen.