Leveraging Implementation Science to Expand Suicide Prevention to Primary Care

Background and Purpose: The prevention of adolescent death by suicide is a critical public health issue. Most suicidal youth (90%) meet with their primary care provider within months preceding a suicide attempt. Yet, their elevated risk for suicide is rarely detected. When it is discovered, adolescents are most often sent to emergency departments where they face extensive wait times and limited, if any, coordinated after care. Integration of evidence-based suicide interventions can expand prevention of adolescent suicide efforts to primary care. However, primary care settings are still variable in their integration of behavioral health care and access to external resources. Little is known about the most effective strategies to successfully implement crisis-oriented suicide prevention interventions in primary care settings. The purpose of this study was to examine determinants of the implementation of an evidence-based suicide prevention intervention in primary care.

Methods: Using a multiple case study design, four clinics were sampled with varying intensity of behavioral health integration and contextual characteristics. Each clinic successfully integrated the evidence-based intervention - Family Based Crisis Intervention (FBCI) – and reduced emergency department referrals for suicidal ideation by 90%. Interdisciplinary participants (N=25) working in a participating clinic completed electronic surveys including measures of implementation (i.e., leadership, climate) and participated in semi-structured qualitative interviews eliciting implementation determinants pre- and post-adoption of FBCI. Guided by the Consolidated Framework for Implementation Research (CFIR), a multiphase hybrid inductive-deductive analytic strategy informed individual case summaries integrating both inductive qualitative thematic coding and descriptive quantitative data. The CFIR also guided case by category matrices that informed the cross-case analyses.

Results: Implementation-focused supervision provided critical and effective ongoing support to social workers’ using FBCI and consultation to the clinic leadership for integration of suicide screening procedures. However, rigid and overburdened clinical workflows inhibited FBCI implementation on multiple levels from interprofessional communication during handoffs to behavioral health staff to poor access to physical meeting space. Previous experience with suicide screening and higher levels of behavioral health integration eased FBCI implementation. While other sites, with easy emergency department access and lower behavioral health integration, required differential strategies to support implementation. The primary responsibility of delivery was with the behavioral health coordinators who were most often social workers. Yet, these coordinators reported this high level of responsibility for meeting the crisis needs of suicidal adolescents is combined with insufficient autonomy and limited resources (particularly time) within the clinical workflow and within their limited hours.

Conclusions and Implications: Clinical supervision provided social workers with critical and responsive support that helped social workers to navigate their primary responsibility for adolescents and to identify potential solutions to encountered implementation barriers (e.g., rigid clinical workflows). Inclusion of increased support and strategies targeting adaptations to clinical workflow and increased resources for social workers can potentially further improve suicide prevention efforts in primary care.