Rapid Referral to Suicide Specific Intervention in Psychiatric Emergency Care

这一修订后的提案是对HSR&D针对自杀问题卫生服务研究的目标征集的回应。 预防越来越多地实施当天精神病急诊，这是一种最佳做法， 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 同一天接受心理健康检查的退伍军人中自杀意念和近期自杀行为的频率 评估，但只有不到一半的退伍军人与这些风险因素从事门诊心理健康 这些任命是在对他们进行初步评估后确定的。为了减少自杀的风险， 从急性到门诊治疗的过渡，目前还不清楚“桥梁”过渡的模型是否应该强调 自杀预防协调小组提供的电话外展服务，或针对自杀的心理治疗， 自杀行为的协同评估和管理（CAMS）CAMS是一个简短的transdiagnosis 循证心理治疗被联合委员会和零自杀框架认可为 适用于有主动自杀意念和/或近期自杀行为的退伍军人。这个单点4- 一项为期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展服务相比， 在同一天进行心理健康评估，并被评估为自杀风险较高。以混合 1型研究设计，我们建议从当天的诊所环境中招募退伍军人，他们报告最近或 在过去3个月内，目前有积极的自杀意念和/或自杀企图。退伍军人将被随机分配 及时启动CAMS或自杀预防协调员的电话外展。主 结果（目标1）是12个月的自杀相关行为或精神病住院率。目的2 对比随机条件之间的运营效率指标，包括退伍军人的 错过了转诊的持续精神卫生保健和紧急护理的预约。我们还将 评估次要结果（例如，自杀意念严重程度）。目标3将研究以下因素的调解影响： 门诊心理健康治疗参与的主要成果。目标4评估对CAMS的保真度， 与结果的关联。忠诚度和面对面的结果是通过使用信息来衡量的 一种名为eScreening的技术，与电子病历集成，用于协调快速 转诊和基于测量的护理。该项目建立在我们的初步数据基础上，这些数据表明， 招募并在当天快速转诊至CAMS治疗是高度可行、可接受的， 潜在的影响力。该项目的创新之处在于其重点是在同一天的过渡性护理干预措施 诊所设置及其整合卫生信息技术，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“自杀特异性”的护理模式。 一旦发现风险，立即进行干预”，并解决了及时自杀影响方面的重要空白 白宫的报告指出了预防策略。该研究还回应了HSR&D精神和 行为健康、获取和护理协调优先领域。我们希望这些数据能提供最好的信息， 在同一天的心理健康服务中预防自杀的做法，许多处于危险之中的退伍军人都可以看到。

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.