The Department of Veterans Affairs has six noteworthy weaknesses in its suicide prevention services, according to a VA Office of Inspector General report.
OIG evaluated 28 Veterans Health Administration facilities across the country between Oct. 1, 2015 and March 31, 2016, to determine compliance with federal guidelines related to suicide prevention. VHA issued guidelines in 2008 to evaluate and monitor high-risk patients, requiring clinicians to create and document suicide prevention safety plans, among other standards.
The office found most facilities adequately responded to referrals from the Veterans Crisis Line and followed up with high-risk patients who missed appointments. The facilities also completed appropriate mortality reviews and issued briefs after a patient died from suicide. However, OIG identified a few significant shortcomings at the facilities.
Here are six weaknesses outlined in the report.
1. Outreach activities. VHA requires each facility complete five outreach activities each month to drive awareness about its suicide resources. Nearly 18 percent of facilities did not meet this standard.
2. Safety plans. Clinicians treating high-risk patients must develop suicide prevention safety plans, which are maintained in patients' EHRs. OIG did not find up-to-date safety plans in 11.4 percent of high-risk patients' EHRs.
3. Inpatient record 'flags.' A clinician who identifies a high-risk inpatient should place a 'patient record flag' in the EHR. In 13.6 percent of high-risk inpatient EHRs, clinicians did not place a flag. The clinician must also alert a suicide prevention coordinator, which did not happen 10.6 percent of the time.
4. Inpatient follow-up. After a high-risk inpatient is discharged, a suicide prevention coordinator or mental health provider must evaluate the patient at least four times over the next 30 days. This process did not take place in 15.3 percent of high-risk cases, according to EHR data.
5. Outpatient record 'flags.' For a high-risk outpatient, a clinician must review patient record flags every 90 days to decide whether to continue the flag. In 25.4 percent of EHRs, clinicians had not documented a review in the past 120 days.
6. Employee training. Under VHA requirements, primary care and mental health providers must undergo suicide risk assessment and management training. However, 45.7 percent of these clinicians had not completed this training within 90 days of hire.
Click here to view the full report.