Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal

Measure Specification

Suicide safety planning (SSP), which involves counseling the suicidal individual around reducing access to lethal means, teaching brief problem-solving and coping skills, and helping the individual increase social support and identify emergency contacts is effective and critical in suicide prevention as echoed in recent clinical practice guidelines and recommendations from the Joint Commission.

It has been identified as the best practice for suicide prevention by the American Foundation for Suicide Prevention and the Suicide Prevention Resource. In fact, this effective suicide prevention initiative has been found to be clinically useful and feasible by both suicidal individuals and clinicians, associated with reduction in suicidal behaviors.

Individuals with suicidal ideation and behaviors also report that the SSP helps them maintain their safety and increases the likelihood of them remaining in care.

Suicide safety plan is a brief intervention that involves working in collaboration with the patient, who is at risk for suicide, to identify and document a written list of warning signs of that the patient is becoming suicidal; coping strategies; sources of support; and means restrictions (Stanley et al., 2016). It must include the following 6 steps, where the provider helps the patient: Recognize the warning signs of the suicidal crisis.

Learn how to employ internal coping strategies without needing to contact another person. Understand the need for and benefits of socializing with family members or others who may offer distraction from the suicidal crisis. Contact family members or friends who may help them resolve the suicidal crisis. Contact mental health professionals or agencies.

Identify ways to make their environment safe (e.g., reduce their access to lethal means, such as firearms).

This measure contains two strata defined by two submission criteria. This measure produces two performance rates There are 2 Submission Criteria for this measure: 1) All patients for whom a suicide safety plan is initiated, reviewed, or updated (concurrent or within 24 hours of clinical encounter) AND 2) All patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) (i.

e., individuals who satisfy Numerator 1) AND reviewed and updated within 120 days after initiation This measure will be calculated with 2 performance rates: 1) Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter) 2) Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation.

For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of MIPS, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.