Youth Suicide Prevention in Primary Care (YSP-PC): The Pennsylvania Model

Guy S. Diamond, Ph.D.1, 2

Matthew B. Wintersteen, Ph.D.3

Sherry Peters, MSW.4

Stanley Mrozowski, Ph.D. 5

Denise Short, M.Ed.5

1 University of Pennsylvania

2 Children’s Hospital of Philadelphia

3 Thomas Jefferson University

4 Center for Child and Human Development, Georgetown University

5 Pennsylvania Department of Public Welfare

Special thanks to those members of the broader team: Kathy Wallace, Linda Wagner,

Rozanne Ciavarella, James Martin, Joseph DeVizia, Dan McGrory, Tammy Saunders,

Doris Arena, Lonnie Barnes, Carol Thornton, Rebecca Dominguez, Connell O’Brien,

Suzanne Yunghans, Angie Halaja-Henriques, Cheryl Bumgardner, Susan Schrand, Allen

Tien at MDLogix, Alana O’Malley, Shannon Chaplo, Paula McCommons, Harriet

Bicksler, Rebecca Dominguez, Tara Gallagher, Deborah Heim, Richard McKeon, David

Litts and to all the PCPs and patients that participated in this pilot project.

Corresponding author:

Guy S. Diamond

3535 Market Street, Suite 1230

Philadelphia, PA 19104

diamondg@email.chop.edu

(215)590-7550

Word Count: 4195 words

Disclaimer: This paper was developed, in part, under grant number SM58386 from

SAMHSA. The views, opinions and content of this publication are those of the authors

and contributors, and do not necessarily reflect the views, opinions, or policies of CMHS,

SAMHSA, or HHS, and should not be construed as such.

Abstract

The Institute of Medicine (2002) has identified primary care as a source for identification,

triage, and brief treatment for suicidal youth. In response, Pennsylvania has developed the

Youth Suicide Prevention in Primary Care (YSP-PC) project: a multidimensional systems

change approach. Five aims characterize the project. 1) Create state and county stakeholder

groups to resolve systems level barriers. 2) Improve the collaboration between medical

and behavioral health providers. 3) Provide training to primary care providers (PCPs) in

suicide risk assessment. 4) Import a web-based screening tool for suicide and related

psychosocial risk factors. 5) Train local therapists in empirically supported suicide

interventions. This paper describes the five aims, barriers and solutions, and the initial

outcome of the project.

Youth Suicide as a Public Health Problem

Suicide is the third leading cause of death in Americans aged 15-24 years with

just under 4,200 deaths in 2007.1 In addition, about one million adolescents attempt

suicide and nearly 500,000 are admitted to psychiatric hospitals from emergency rooms

for suicide attempts or serious suicidal ideation each year.2 In fact, suicide accounts for

more deaths than the seven leading non-injury-based medical conditions combined.

Suicidal thoughts and behaviors lead to emotional and financial costs for patients,

parents, and the treatment system.3

The IOM report of 2002 and the National Strategy for Suicide Prevention4 clearly

identified primary care as a potential source for identification, triage, and brief intervention

for suicidal youth. Over 70% of adolescents see a physician at least once a year5 making

primary care an excellent gatekeeper for adolescent suicide and other behavioral health

needs.6,7

Physicians also treat a myriad of psychiatric conditions.8,9

One study even found

that psychosocial issues are present in nearly 70% of primary care visits.10

Prevalence

data on patients presenting in primary care specifically with suicidal behavior or ideation

is limited. However, patients with clinical or sub-clinical depression are highly likely to

use emergency and ambulatory services, compared to patients with other behavioral health

conditions.11-13

In the Annenberg Adolescent Mental Health Project14

pediatricians

believed 16% of adolescents in the last year were depressed, and 5% were at risk for

suicide.

Given these data, a call for behavioral health screening in primary care has been

renewed.15-17

In particular, the American Academy of Pediatrics, the American Academy of

Child and Adolescent Psychiatry, and the U.S. Prevention Services Task Force have

recommended universal screening for depression when follow-up services are

available.18,19

In addition, the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO)20

now requires suicide screening for youth being treated for

behavioral health problems in all inpatient and ambulatory services (when part of an

accredited hospital), and strongly recommends an assessment of other behavioral health

problems (e.g., child abuse, substance use, etc.).

Unfortunately, screening for suicide risk within the primary care setting presents

numerous challenges. Increasing identification rates without improving PCP assessment

skills and referral options will only increase provider anxiety and clinical burden. Suicide

screening in particular, generates concerns about patient safety and practice liability.

Therefore, to address this multi-faceted challenge, we need a broad-based approach to

screening; one that create changes to the system and context, rather than merely adding a

new procedure (i.e., screening).

The National Strategy for Suicide Prevention4 advocates for a public health

approach to suicide prevention. Within this context, there are five evidence-based

practices utilized systematically21

: surveillance, identifying risk and protective factors,

and developing, implementing, and evaluating interventions. Using this framework, we

developed the Youth Suicide Prevention in Primary Care (YSP-PC) project. The project

was funded by the Substance Abuse and Mental Health Services Administration

(SAMHSA), as appropriated by the Garrett Lee Smith Memorial Act, and awarded to the

Pennsylvania Department of Welfare.

The project had five aims (see Figure 1). First, we developed state and local

stakeholder’s task forces to ensure that the program fit within the ecology of the targeted

communities. Second, we improved partnership between local primary care and

behavioral health providers. Third, we implemented a web-based screening tool that is

completed and scored before a visit. Fourth, we provided training to primary care staff

about suicide risk assessment and related behavioral health concerns. Fifth, we provided

behavioral health agencies training in empirically supported treatments for youth suicide

(e.g., CBT and family therapy). This paper provides an overview of the YSP-PC project,

including the specific components, some implementation barriers and solutions, and our

current outcomes.

Aim #1: State and Local Stakeholder Development

Successful dissemination of new ideas and program changes requires strong buy-

in from a wide range of stakeholders. These representatives should be involved in

planning, implementing, evaluating, and promoting all aspects of a project’s activities.

Diffusion of new ideas works best when patients and their families, providers, third party

payers, and policymakers feel the innovation addresses some of their specific needs and

they feel part of the process.22

This participatory-action approach23

became particularly

important in this project as we confronted the chasm between medical and behavioral

health. Divides were evident among state agencies responsible for these two service

delivery systems, insurers who paid for behavioral health and medical care, and

professional organizations that represented these two communities. Without attention to

policy and organizational barriers, these conflicts would have inhibited our progress on

the ground with primary care and behavioral health providers. Therefore, our approach

began with state policy makers and organizational leadership.

We initially struggled with where to house the grant. The Pennsylvania

Department of Health as well as the Office of Injury Prevention oversees many policy

issues and funding opportunities in the medical community. However, the Office of

Mental Health and Substance Abuse Services (OMSAS), in the Department of Public

Welfare, oversees behavioral health and the state’s youth suicide prevention monitoring

committee. Negotiations eventually resolved this, but it was important to sort out in a

mutually agreed upon way.

We then partnered with key medical and nursing associations: Pennsylvania

Chapter of the American Academy of Pediatrics, Pennsylvania Academy of Family

Physicians, Pennsylvania Coalition of Nurse Practitioners, and the Pennsylvania

Association of Community Health Centers. These groups did not usually partner with

mental health organizations, but the emergence of the medical home model helped forge

these new relationships. For this project, the medical associations provided the necessary

credibility and visibility for our project in the medical community. Each group received a

small stipend to attend monthly planning meetings, identify possible performance sites,

co-sponsor annual webinars on topics relevant to suicide prevention, and generally serve

as ambassadors for the project at state and local events.

We also reached out to the Pennsylvania Youth Suicide Prevention Initiative

(PAYSPI) Monitoring Committee (see www.payspi.org). This working group was

established in 1990 and serves as a public-private partnership to promote the state suicide

prevention plan. The group was a uniquely successful interdisciplinary committee with

representatives from state offices in behavioral health, physical health, substance abuse,

education, and juvenile justice, as well as mental health provider organizations, parent

advocacy groups, academicians, and suicide survivors (e.g., the parents). This committee

previously launched a state suicide website with resources and announcements which has

been further developed by this project. The Chair of the Monitoring Committee, also the

Division Chief of Policy, Planning, and Program Development in the Bureau of

Children’s Behavioral Health in the DPW-OMHSAS, spearheaded the YSP-PC project

and served as the initial principal investigator of our grant.

An additional state-level effort focused on the development of county suicide

prevention task forces, particularly among the targeted counties for the project, but also

across the Commonwealth of Pennsylvania. In the first year of the project, we established

a new county task force in one targeted county, revived one in another county, and

partnered with a highly active task force in the third county. These task forces consist of

representation from local government, schools, religious groups, behavioral health,

primary care, Emergency Departments, police, coroner’s office, child death review

teams, survivors of suicide, and the media. In the third year of the project, we expanded

our task force development efforts across the state. We organized four state wide regional

task force meetings. We aimed to assess needs and activities, increase cross-county

communication through our suicide website, and garner future support for the project.

Thirty-five (of 67) counties were represented by 137 participants. Many of the groups

expressed interest in helping bring the YSP-PC project to their counties if future funding

were obtained.

A number of other state level efforts were accomplished. These included a) a

statewide survey of 670 PCPs regarding behavioral health and suicide prevention

practices,24

b) six webinars on topics relevant to suicide prevention and integrative

primary care, c) presentations at numerous state medical and behavioral health meetings,

d) coordination of a state leadership summit attended by state, private, and community

sectors, and e) a bi-monthly leadership call with Pennsylvania’s Office of Medical

Assistance Programs to explore shared resources and potential reimbursement for suicide

risk screening. Finally, we have supported the development of the Pennsylvania Health

and Mental Health web-based learning collaborative

(http://community.networkofcare.org). Organized by medical and behavioral health

leadership across the state, this group now serves as a central clearinghouse for all related

state efforts on the integration of behavioral health services into medical care. These

projects have given our program good visibility in the state and helped garner more

attention to these issues.

Community-Level Stakeholder Development

At the county level, we sought to develop similar stakeholder/advisory groups in

order to better understand the culture and resources of those communities. We reached

out to the county Mental Health and Mental Retardation (MH/MR) Directors. Given their

reporting relationships to the state and their oversight of the behavioral health systems

within the county, they had appropriate leverage to support the project’s aims. We

therefore, funded a part-time coordinator in each county through this office to serve as

the local liaison between the PCP and behavioral health providers. Start up time took

about 12 hours and then follow up took about 1-2 hours a week per practice. The liaison

identified interested practices, coordinated meetings between PCPs, project staff, and

behavioral health agencies and providers, and developed behavioral health resources in

the PCP office including pamphlets, posters, and wallet cards. They also educated

providers about available behavioral health services (e.g., laminated phone lists,

identified new providers, tips on navigating the system), and facilitated relationship

building between these systems of care. Perhaps most importantly, these coordinators

became systems navigators for patients identified as in need of behavioral health services.

When a suicidal patient presented in a primary care practice, the coordinator would be

called to help navigate the system to ensure follow-up care. As the relationship between

the provider systems improved, this navigator function was needed less. While behavioral

health has done a good job partnering with the school systems over the past ten years, no

similar infrastructure exists for partnering with the PCP community. Our liaisons may be

one model to improve this effort.

Recruiting Primary Care Performance Sites

Although the patients are the beneficiaries of the project, the target audience is the

PCP office. Thus, recruitment efforts focused on identifying medical practices to

participate in the YSP-PC project. We began with talks in the community, mailings to all

PCP providers, activating old collaborations between medical and behavioral health

services, and outreach from our state medical and nursing associations, including the

medical home association and the federally funded health centers. Regional care

coordinators from the Medicaid office who made monthly visits to each practice also

assisted in identifying potential participating practices. Word of mouth from successful

practices, however, was the most effective recruitment strategy. Once a practice

expressed an interest in the project, the county coordinator did a site visit to determine

practice readiness and then scheduled for training and screening initiation.

Aim #2: Coordination of Medical and Behavioral Health Services

Lack of easy access to behavioral services is the most frequently endorsed barrier

to screening for behavioral health problems.25

PCP’s complain that they can not access

services for patients, never hear back from behavioral health providers, and are not

confident about the quality of treatment.24,26

Yet, despite over three decades of interest27

, the

integration of behavioral and medical services has been limited2,7,28,29

particularly in

pediatric and adolescent medicine.14

Several relationship models for partnership between

these provider communities have been proposed. These models include coordinated

services (screen and referral), collocated services (behavioral health in the same

building), and integrated services6,24

(team approach with one treatment plan).While

collocation and integration might be ideal, it is not always feasible. Thus, this project

focused on the coordination of care model.

Enhancing the coordination of care began with understanding the PCP’s concerns.

The two most common complaints were the lack of access to, and communication with,

behavioral health providers. In response, we identified local behavioral health service

providers with whom the PCPs had successfully partnered with in the past. This included

outpatient services, psychiatrists, independent practitioners, and crisis teams. We invited

those providers to a meeting at the PCP office (a surprisingly unique event). Meeting

face-to-face, learning each other’s names, and sharing their mutual concerns was a new

and productive experience. We also had behavioral health providers leave a stack of

release of information forms, so patients could sign them before leaving the PCP office.

Some behavioral health agencies set up a single point of contact, and identified a person

to facilitate the referral: the PCP liaison. We developed a one-page, comprehensive

referral guide for the PCPs detailing how to access these services (e.g., who to call and

how to follow up). This was a new resource for the PCP community and remarkably well

received and used. Finally, we invited behavioral health staff to the PCP office for a

suicide risk assessment training (see below). This provided a joint training experience

and an opportunity for further relationship development. We also encouraged providers to

offer future trainings to each other in their respective expertise. Building these personal

relationships has been our most effective systems change strategy. As relationships

developed, policies and procedures followed. In general, we tried to find at least one

behavioral health provider agency committed to working more closely with each primary

care practice site.

Aim #3: Suicide Risk Assessment, Training, Education, and Resources

Physician suicide education is one of the two empirically proven and successful

suicide prevention strategies that results in a significant reduction in the suicide rate30

(Lethal means restriction is the other intervention). Yet, formal training for primary care

professionals and medical students remain limited.31

Thus, developing feasible training

programs for PCP’s became a critical project component.

Our main activity was directed at PCP’s in participating practices. First, we

worked with the American Association of Suicidology (AAS) to modify Recognizing and

Responding to Suicide Risk in Primary Care to target adolescent providers (RRSR-PC-

Y).32

This 90-minute training for PCP’s, physician assistants, and other healthcare

workers in primary care settings improves the provider’s ability to identify, manage, and

treat patients at risk for suicide. It features a one-hour PowerPoint presentation with

additional video vignettes demonstrating suicide risk assessment strategies with a patient.

The RRSR-PC is listed as a Best Practice under Section III of the SPRC/AFSP Best

Practice Registry. One of the members on the executive committee of the YSP-PC project

visited each participating primary care site and provided the training.

We also distributed to each practice the Suicide Prevention Toolkit for Rural

Primary Care.33

Developed by the Western Interstate Commission for Higher Education

(WICHE) in collaboration with SPRC, this web-based or hard copy manual helps

providers improve the integration of suicide risk assessment and identification into their

practice. This includes overcoming obstacles of visit time, stigma, poor access to

behavioral health services, strategies for educating staff, billing for behavioral health

services in primary care, and posters and pocket cards to increase awareness and

education about suicide risk (http://www.sprc.org/pctoolkit/index.asp).

Several other educational activities were pursued. First we worked with the

medical associations to provide statewide webinars led by regional and national experts

to their members. Topics included suicide epidemiology and assessment, medication

management of depressed adolescents, motivational interviewing, and using the new

AAP mental health toolkit for pediatricians.34

Second, we presented similar topics at

numerous medical association meetings. Third, we developed a web-based, asynchronous

learning curriculum for nurses and nurse practitioners.35

Each of these resources offered

enhanced learning capabilities to providers from many medical and nursing disciplines

across the state.

Aim #4: Provide Participating PCPs Free Access to a Web-Based, Patient Self-Report,

Psychosocial Screening Tool

At the heart of our project is the implementation of the Behavioral Health Screen

– Primary Care (BHS-PC).36

The BHS-PC is designed to assess all the domains

recommended for a well visit for adolescents between the ages of 12 and 24. It is

composed of 13 modules: demographics, medical, school, family, safety, substance use,

sexual risk, nutrition and eating, anxiety, depression, suicide, psychosis, trauma, and

abuse. There are 55 required items and 37 follow-up items, taking about 10 to 14 minutes

to complete. The program scores and generates a report, and the provider reviews the

report before meeting with the patient. The report is then integrated into the medical

record. The BHS-PC has strong psychometric properties and has been deemed feasible by

patients and providers.36

A shortened version has been developed for the Emergency

Department.37

The BHS-PC was also recently translated into Spanish.

All participating primary care offices received free access to the BHS-PC. Most

practices had internet access and we provided laptop computers, printers, and rolling carts

when needed. Parents were given a brief handout describing the rationale for screening,

the process, and confidentiality. Either front desk or nursing staff registered patients.

Administration of the BHS-PC typically occurred in the waiting or exam room, but could

be done from home. When complete, the computer scored the BHS-PC and immediately

generated a report that was sent to a designated printer. The PCP reviewed the report

prior to meeting with the patient. The PDF of the report was scanned or pasted into the

EMR. If an adolescent endorsed suicidal risk thought or behavior, the physician evaluated

the need for services. If necessary, medical staff activated a practice-based suicide

response plan developed as part of the project.

Practice patterns of the BHS-PC varied across sites. Average monthly screening

rates ranged from two to thirty-two patients a month. While we advocated for universal

screening,38

many providers conducted indicated screening; only evaluating adolescents

for whom they had concerns. In general, offices where staff were computer savvy or had

EMRs were more likely to use the tool frequently. Unfortunately, none of the PCPs

received third party reimbursement for the screening, a practice that has been shown to

increase screening rates.39

Aim#5: Provide Clinical Training to the Partnered Behavioral Health Providers

Interest in importing evidence-based behavioral health practices into community

treatment centers has grown exponentially.40,41

These treatments have demonstrated

efficacy in research settings and effectiveness in real world settings. These models

improve clinical care, treatment fidelity, and outcomes while often decreasing costs.42

Effective treatments for suicidal youth are limited, but have shown effectiveness.43

Therefore, we set out to enhance the skill set of the behavioral health providers who took

referrals from participating PCPs.

To accomplish this, we provided training workshops and ongoing supervision in

two empirically supported treatment models validated for working with suicidal youth.

One treatment was cognitive behavioral therapy for adolescent depression and suicide.44

This treatment is designed to improve techniques for identifying and changing cognitions

and exploring underlying core beliefs of the adolescent. The other treatment was

Attachment-Based Family Therapy (ABFT).45

ABFT aims to resolve family conflicts that

are inhibiting the parents from being a more protective resource to the suicidal

adolescent. Although both treatments were well received in the counties, attendance at

follow up training and supervision was hard to maintain. Providers in community

agencies have high productivity demands and require weekly administrative and clinical

supervision. Adding a new, external training demand seemed more burdensome than

helpful. It became clear over the course of the project that changing behavioral health

clinical practice was a mission beyond the scope of this project. Consequently, we scaled

back this aim and have been planning trainings related to outpatient suicide crisis

management.

Current Practice-Based Outcomes

Even with our challenges and ambitious agenda, the program demonstrated some

good success. Over the course of the project, we formally approached 17 practices, and

11 elected to participate. Reasons for practices refusing to participate included a) fears of

workflow change, b) liability concerns, c) absence of referral options, and d) comfort

with current process and procedures. When a practice did elect to participate, screening

rates varied between practices, but stayed fairly consistent within practices. From day

one, some practices screened ten to fifteen patients per week, some screened 3 to 5 per

week and others screened one or fewer per week. Some practices gave their patients the

choice to complete the screen as if it were separate from the visit. This led to high refusal

rates. Other practices presented the screen as part of the visit as requested by the doctor.

This led to very high compliance rates. Some practices felt the screen was duplicative

with current procedures and did not want to change their procedures. Others adopted the

screen as standard practice. The culture and leadership of the practice greatly influenced

the overall response to screening and the project in general.

Current Clinical Outcomes

At the date of submitting this paper, we had screened 1042 patients. The numbers

increased over time as we added more practices. Within this sample, we identified 169

patients (16.2% of overall sample screened) who endorsed having thought about killing

themselves some time in their life. Analyses of the BHS-PC data suggest that patients

endorsing lifetime suicidal thoughts were more at-risk for behavioral problems than

patients reporting no prior thoughts of suicide, but less at risk than patients with current

suicidal ideation.46

Of the 169, 44 patients reported current thoughts about killing

themselves (4.2% of the total sample). This high rate may be a function of indicated

screening practices by the providers. In a study with universal screening in urban primary

care, we found only 3.6% of youth endorsed any history of suicidal ideation.47

Still,

these data suggest that, if screened, we could identify nearly 1 in 5 patients at risk for

suicide, certainly warranting a follow up evaluation by the PCP, if not a referral to

specialty mental health services. In fact, of those at risk (N=169), 14 (8.2%) were already

in treatment, 35 (20.7%) refused treatment, and 75 (44.3%) accepted the referral and

went to treatment (see Table 1).

In addition to identifying those who endorsed suicidal ideation and/or behaviors,

the BHS-PC detects those patients with other psychosocial problems that place them at

risk for mental health distress let alone suicide risk. Our data indicate that, in all, 303

(about 30%) of youth met the BHS-PC clinical cut off for mental health distress on

depression, trauma, substance abuse, eating disorder, or anxiety (Table 2). Many of these

non-suicidal, but emotionally distressed youth were referred to outpatient care as well.

Providers have been mainly positive about the overall project even if they under used the

BHS-PC (provider satisfaction data is currently being collected). Patient satisfaction with

the BHS-PC was also very high. Only 16.6% of youth reported that they felt

uncomfortable answering the screening questions while 90.2% felt that it was a good idea

for their medical provider to ask these types of questions.

Future Directions

Building on our success, we now look to explore sustainability. How can this

important public health project survive without, or with less, extramural funding? First,

we have learned that practice readiness is essential for the success of the YSP-PC project.

Thus, we have begun to partner more closely with the state medical home organization

and medical home practices. These practices already engage in innovative and integrative

models of care making the incorporation of the YSP-PC project more acceptable.

Second, we aim to build a comprehensive website that electronically houses project

resources. This will include training materials, archived webinars, tool kits, the BHS-PC,

and links to other national and local resources. Our software partner, MDLogix, Inc., will

host the website and license access to practice or medical systems. Third, we have now

demonstrated that if PCP’s screen regularly, a larger number of patients will be identified

that are in need of behavioral health services. Given the case volume, collocating

behavioral health assessment and treatment services becomes a viable business model for

behavioral health providers. Fourth, we continue to discuss with private and public

insurance companies the possibilities of reimbursing PCPs’ for use of the screening tool.

In Pennsylvania, there is already precedence to reimburse for autism screening. We hope

they will extend this practice to adolescent mental health. SAMHSA recently called for

comments on a proposal for reimbursement for depression and substance abuse screening

in primary care. Sustainability will be dependent on business models like this that make it

financially viable to engage in these activities.

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Figure 1. Youth Suicide Prevention in Primary Care: The Pennsylvania Model

Referral to a

Better

Prepared

Behavioral

Health System

Stakeholder

Involvement

State Level:

Policymakers

Medical associations

Third party

payors

State Suicide Monitoring Committee

State suicide

task force development

Webinars

Needs

assessment

Learning community

Community Level:

MH/MR

Directors

County coordinator

Suicide task

forces

Coordination of

Medical and

Behavioral

Health Services

Identify BH provider partners

Face-to-face provider

meetings

Behavioral health referral guide in primary care

Shared training

experiences

Systems navigator for suicidal youth

Exchange of release of information forms

Single point of

contact at BH

agencies

Training

Primary Care Providers:

Suicide Prevention Toolkit

Suicide risk assessment

Pharmacological approaches to depression treatment

Motivational

interviewing Behavioral Health Providers:

Evidenced-based

practices for suicidal youth

Suicide risk assessment

Safety planning

Screening

Behavioral Health Screen (BHS-PC)

Web-based

Suicide risk, psychiatric symptoms, risk behaviors

Validated with strong psychometric properties

Aggregate data

at patient-, provider-, practice-, and state-level.

Integrate with

electronic medical record (EMR)

Behavioral helath

Screneing tool

Evaluate Outcomes and Report Back to Stakeholders for

Modifications, Revisions, Reinvestment, and Dissemination

Table 1. Number and percentage of patients identified for suicide, referred for services, and

attended services

County

Identified

for

Suicide

Risk

Referred

for

Services

Already

attending

Services

Attended

Services

Refused

Services

County 1

116 84

(72.4%)

13

(11.2%)

49

(42.2%)

22

(19.0%)

County 2

35 28

(80.0%)

1

(2.9%)

16

(45.7%)

7

(20%)

County 3

16 13

(81.2%)

0

(0%)

10

(62.5%)

6

(37.5%)

Total

169 125

(74.0%)

14

(8.2%)

75

(44.3%)

35

(20.7%)

Note. Missing referral data for 22 patients. Missing service utilization data for 57 patients, 21 of

which are unable to be contacted.

Table 2. Number and percentage of patients screened and identified for suicide and behavioral health problems

County

Total #

Screened

Suicide

Depression

Anxiety

Trauma

Eating

Disorder

Substance

Abuse

County 1

675

117

(17.3%)

155

(22.9%)

227

(33.6%)

141

(20.9%)

20

(2.9%)

27

(4.0%)

County 2

112

16

(14.2%)

18

(16.07%)

41

(36.6%)

31

(27.7%)

1

(0.9 %)

2

(1.8%)

County 3

255

36

(14.1%)

50

(19.6%)

77

(30.2%)

68

(26.7%)

8

(3.1%)

10

(3.9%)

Total

1,042

169

(16.2%)

223

(21.4%)

343

(32.9%)

240

(23.0%)

29

(2.8%)

39

(3.7%)