In This Issue

• National Suicide Prevention and National Recovery Month 
• New COE-NF Podcast: Insights on the Benefits of Recovery Supports
• Nursing Facility Guidance: Minimum Data Set (MDS 3.0)
• Subject Matter Expert Articles
  • Addressing Health Equity Disparities in Suicide Prevention
  • Case Study: Screening for Suicide Risk in Skilled Nursing Facilities 
• Office Hours
  • Managing Substance Use Disorders in Nursing Facilities 
  • CARES® Serious Mental Illness™
• COE-NF Resources
  • Columbia Suicide Protocol
  • Substance Use Disorder: Bite-sized Learning Disorder Module
  • Substance Use and the Brain: Module
  • Major Depressive Disorder: Bite-sized Learning
• Did You Know?
• Save the Date: Upcoming Trainings

September is National Suicide Prevention and National Recovery Month. Suicide Prevention Month is a time to learn ways to prevent suicide, share messages of hope, and remember lives lost to suicide. National Recovery Month is an opportunity to raise awareness about recovery from mental health and addictions. Get your nursing facility involved during this important month.

Suicide Prevention Activities:

• Visit the Suicide Prevention Resource Center to get involved in prevention activities in your state.
• Use the Zero Suicide Toolkit to create a system dedicated to resident safety. 
• Register for the COE-NF training on Changing the Narrative on Suicide Through Addressing Suicidal Behaviors in Nursing Facilities.   

Recovery Month Activities:  

• Access the Substance Abuse and Mental Health Services Administration (SAMHSA) Recovery Month Toolkit for suggested social media content and resources to learn more about supporting residents in recovery.
• Host Alcoholics Anonymous and/or Narcotics Anonymous recovery support meetings at your nursing facility. 
• Submit a request to the COE-NF for support on how to start an in-house recovery support group for your facility.

In this episode, we welcome back David McKay, a substance use counselor who previously shared his inspiring personal journey from substance use recovery to becoming a counselor in an Alliant Health Solutions' Making Healthcare Better podcast titled From Substance Use to Healing Hands – A Substance Use Counselor’s Inspiring Journey. This time, David returns to provide valuable professional insight into the resources available for sustaining recovery support services.

Nursing facilities must utilize the Minimum Data Set (MDS 3.0) to collect specific information through resident interviews. This data is crucial for developing individualized care plans prioritizing quality care for residents enrolled in Medicare or Medicaid programs. To maintain continuity and support person-centered care, it is essential to consistently monitor each resident’s care, health, and overall well-being. Facilities should incorporate regulatory best practices by completing quarterly MDS assessments and conducting assessments whenever a change is identified in a resident's condition. Additionally, if a resident is discharged and readmitted, they should be reassessed to note any significant change in condition. While MDS 3.0 focuses on broader health and functional aspects, it can also prompt staff to investigate a resident’s history and needs further, including screening for suicide risk.

The Patient Health Questionnaire 2 to 9 (PHQ-2) and (PHQ-9) are incorporated into the MDS 3.0 as part of the comprehensive assessment process. This integration helps identify residents who may be experiencing symptoms of depression or even suicidal ideation. Residents are routinely screened using the PHQ-2 as part of the MDS 3.0 assessment. If the PHQ-2 screens positive, indicating potential symptoms, the PHQ-9 is administered for a more detailed assessment. Staff must be vigilant in recognizing and addressing signs of distress and assessing responses to suicidal thoughts. When a resident expresses suicidal thoughts, it is crucial for staff to conduct a thorough evaluation of the severity of the ideation, any specific plans, and related risk factors. Collaboration with mental health professionals and implementation of safety planning are key interventions to support suicide prevention.
 

Resources:

• Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual
• Patient Health Questionnaire 9 - COE-NF
• Patient Mood Interview (PHQ-2 to 9©) Video Tutorial

Keeping you updated with the latest research, advancements and best practices in managing and addressing behavioral health conditions in nursing facilities.

Article Contributed by Whitney O’Donnell, MBA, BSN, RN, CPHQ 

Recent research has shown significant health equity disparities in suicide risk among older adults in nursing care facilities (Jain et al., 2021). Key risk factors include depression, health deterioration, and duration of residence, yet translating research into effective prevention strategies remains challenging (Mezuk et al., 2015; Murphy et al., 2018). Societal biases questioning the value of preventing suicide among older adults from marginalized backgrounds can influence our approach, often neglecting the specific needs of these vulnerable groups (Draper, 2015; Murphy, 2016).

Suicide rates vary by age, gender, and socioeconomic status, with older men from disadvantaged backgrounds showing consistently high rates globally, largely due to limited access to mental health care and lifelong inequalities (WHO, 2014; Freeman et al., 2017). Women encounter unique barriers, including cultural norms around seeking help (Blisker and White, 2011).

Nursing facilities play a critical role in addressing suicide risk, as many residents spend their final years in these settings. Effective intervention requires understanding and addressing health equity disparities that shape our care environments and policies (Conwell et al., 2011). Given the diverse populations in nursing facilities, tailored suicide prevention approaches are essential (Ball et al., 2014). Suicidal thoughts are prevalent among nursing residents from marginalized communities, often linked to depression, isolation, and systemic discrimination (Mezuk et al., 2014).

After a suicide, effective communication and support are crucial for mitigating trauma and fostering community resilience (SAMHSA, 2011). Nursing facility teams must advocate for policies that promote behavioral health equity and suicide prevention for all residents, emphasizing empathy, cultural competence, and dignity.

In conclusion, addressing behavioral health equity disparities in suicide prevention presents both challenges and opportunities. By acknowledging and understanding these disparities, we can enhance the well-being of all residents in care.  

References: https://doi.org/10.1017/s0144686x20000173

Mezuk, B., Lohman, M., Leslie, M., & Powell, V. (2015). Suicide Risk in Nursing Homes and Assisted Living Facilities: 2003- 2011. American journal of public health, 105(7), 1495–1502. https://doi.org/10.2105/AJPH.2015.302573

Mezuk, B., Rock, A., Lohman, M. C., & Choi, M. (2014). Suicide risk in long-term care facilities: a systematic review. International journal of geriatric psychiatry, 29(12), 1198–1211. https://doi.org/10.1002/gps.4142

Murphy, B. J., Bugeja, L. C., Pilgrim, J. L., & Ibrahim, J. E. (2018). Suicide among nursing home residents in Australia: A national population-based retrospective analysis of medico-legal death investigation information. International journal of geriatric psychiatry, 33(5), 786–796. https://doi.org/10.1002/gps.4862

Draper, B. (2015). Elderly men have the highest suicide rate–and ageism stops us from doing something about it. The Conversation. Available at https://theconversation.com/elderly-men-have-the-highest-suicide-rate-and-ageism-stops-us-from-doing-something-about-it-46923.

Freeman, A., Mergl, R., Kohls, E. et al. A cross-national study on gender differences in suicide intent. BMC Psychiatry 17, 234 (2017). https://doi.org/10.1186/s12888-017-1398-8

Bilsker, D., & White, J. (2011). The silent epidemic of male suicide. British Columbia Medical Journal, 53(10). https://bcmj.org/articles/silent-epidemic-male-suicide
Ball, M. M., Kemp, C. L., Hollingsworth, C., & Perkins, M. M. (2014). “This is our last stop”: Negotiating end-of-life transitions in assisted living. Journal of Aging Studies, 30, 1-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4082797/

Conwell, Y., Van Orden, K., & Caine, E. D. (2011). Suicide in older adults. The Psychiatric Clinics of North America, 34(2), 451–ix. https://doi.org/10.1016/j.psc.2011.02.002

Ball, M. M., Kemp, C. L., Hollingsworth, C., & Perkins, M. M. (2014). “This is our last stop”: Negotiating end-of-life transitions in assisted living. Journal of Aging Studies, 30, 1-13.

Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities. Substance Abuse and Mental Health Services Administration. (2011). https://store.samhsa.gov/product/promoting-emotional-health-and-preventing-suicide/sma10-4515

Article Contributed by Jean Lyon, Ph.D., APRN, FNP-BC, PMHNP-BC, NEA-BC, CIC

Suicide in older adults is a public health emergency, and nursing facility residents have been found to have rates comparable to the general population (Mezuk, Lohman, Powell & Leslie, 2015). Compounding variables for increased suicide risk can include those with psychiatric and neurocognitive disorders, social isolation, bereavement, cognitive impairment, difficulty with decision-making, and physical illness (Barak & Gale, 2019). For a nursing facility resident, suicidal ideation is highest within the first seven weeks of admission (Temkin-Greener et al., 2020). Ensuring an accurate psychiatric evaluation is completed on admission and identifying key risk factors is crucial for resident safety. This may sometimes require coordination with an outside provider.

Clinical Scenario and Background
Mr. Davis is a 79-year-old male who recently lost his wife to cancer. They had been married 52 years and have two grown sons who live across the country. Following his wife’s death, Mr. Davis was found walking outside of his house, disoriented and wandering in the neighborhood and required assistance from his neighbors to return home. This has occurred on three separate occasions. His sons decided to move him from his home and to a nursing facility closer to where they live.

Mr. Davis has a history of severe depression following retirement. He did not respond to medications for depression and was treated using electro-convulsive therapy (ECT) treatment. He has a medical history that includes hypertension and uncontrolled Type 2 Diabetes. 

When admitted to the nursing facility, Mr. Davis was evaluated by a psychiatric physician assistant and diagnosed with severe depression. He was screened for suicide risk using the Columbia Suicide Severity Rating Scale and found to be at moderate risk. Mr. Davis stated that he was not considering suicide. He was prescribed an anti-depressant. While cleaning rooms, the housekeeper entered the bathroom and found Mr. Davis trying to hang himself with the shower curtain. 

What factors should we have considered in the management of Mr. Davis? What could have been done differently?

Risk Factors
We know that Mr. Davis has several risk factors that should be considered: He was assessed with a moderate risk for suicide. He recently lost his wife of many years, his sons relocated him away from friends, resulting in social isolation and the most important is his history of severe depression with life changes and past non-responsiveness to anti-depressant medications. 

Need for Environmental Safety Evaluation 
When the facility determined that Mr. Davis was at moderate risk for suicide, the entire team should have been notified, and Mr. Davis should have been placed on one-on-one monitoring or a more stringent monitoring status. To maximize safety, a deeper consideration of Mr. Davis's physical environment could have helped this situation. While it’s not specific to nursing facilities, The Joint Commission has an Environmental Risks for Suicide Assessment Checklist that facilities can use for residents with increased risk for suicide.

Need for Psychiatric Care
Because of Mr. Davis’ past psychiatric history, admission to an acute psychiatric or geriatric psychiatric facility is another consideration for providing a safer treatment setting, provided Mr. Davis meets the admission criteria. An intensive outpatient psychiatric treatment program would also be an alternative option. If Mr. Davis had been transferred to a psychiatric or intensive treatment program, a transfer back to the nursing facility would have been appropriate following treatment and stabilization. 

References:
Barak, Y., & Gale, C. (2019). Suicide in Long-Term Care Facilities—The Exception or The Norm? JAMA Network Open, 2(6), e195634. https://doi.org/10.1001/jamanetworkopen.2019.5634 

Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities. Substance Abuse and Mental Health Services Administration. (2011). https://store.samhsa.gov/product/promoting-emotional-health-and-preventing-suicide/sma10-4515 

Temkin-Greener, H., Orth, J., Conwell, Y., & Li, Y. (2020). Suicidal Ideation in US Nursing Homes: Association with Individual and Facility Factors. The American Journal of Geriatric Psychiatry 28(3), 288-298. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050379/ 

Have mental illness and substance use questions? We have the answers! Join us for office hours to talk with the experts.

Managing Substance Use Disorders in Nursing Facilities

Interested in receiving expert answers to substance use challenges you are facing in your nursing facility? Join Dr. Jen Azen and Dr. Swati Gaur, Subject Matter Experts, as they answer questions related to your complex cases. No question is too big or too small!   
  
Join our monthly office hours on the third Friday of each month from 1-1:30 p.m. ET to get answers directly from the experts working in nursing facilities!  
  
Audience: Appropriate for clinicians, nurses, administrators, and social workers. 

CARES® Serious Mental Illness™   
 
The COE-NF is making the CARES® Serious Mental Illness™ Online Training Program available to CMS-certified nursing facilities at no cost. CARES® Serious Mental Illness™ focuses on how to develop care strategies for individuals diagnosed with a Serious Mental Illness (SMI) and how an SMI differs from dementia.  
 
Interested in learning more about CARES® Serious Mental Illness™ before committing, or have general questions about the program?  
 
Join our ongoing monthly office hours meeting on the fourth Wednesday of each month from 2:30-3 p.m. ET for an open discussion on implementation, benefits, case studies, and successes. 
 
Audience: Appropriate for staff at all levels of care  

The COE-NF developed the following resources that nursing facilities can use to educate the team about The Columbia Suicide Protocol, Substance Use Disorder and Major Depressive Disorder.

Columbia Suicide Protocol
Use these six simple questions from the Columbia Protocol to identify whether a resident is at risk for suicide. Assess the severity and immediacy of that risk and determine the level of support the resident needs. Download Resource

Substance Use Disorder: Bite-Sized Learning
Learn about substance use disorders and actionable steps nursing facility staff can take to support residents with this condition. Watch Video

Major Depressive Disorder Bite-Sized Learning
This video defines Major Depressive Disorder (MDD), shares the signs and symptoms of this disorder, reviews treatment options, and identifies ways to support residents diagnosed with MDD. Watch Video

National Hispanic Heritage Month is recognized from September 15 to October 15. This is a time meant to honor the culture of both Hispanic and Latino Americans.

Nearly 22% of Hispanic and Latino Americans reported having a mental illness (SAMHSA 2023).

During National Hispanic Heritage Month, examine how your facility is promoting access to mental health treatment for Hispanic and Latino residents. 

Changing the Narrative of Suicide by Addressing Suicidal Behaviors in Nursing Facilities

• Identify at least two modifiable risk factors for suicide.
• Outline at least two protective factors for suicide.
• Discuss at least two practical steps nursing facilities can take to reduce the risk of suicide among their residents.

Understand the Science of Addiction and Recovery

• Understand the science of addiction. 
• Explore the complex needs of nursing home residents with SUD. 
• Learn strategies that nursing facility staff can use to work with SUD residents. 
• Gain an awareness that recovery is possible from an individual with lived experiences in long-term recovery.
• Gain an understanding of the Twelve Steps Recovery Program.

Mental Health First Aid (MHFA)

This session provides a MHFA certification for three years.

The training covers: 

• Common signs and symptoms of mental health and substance use challenges.  
• How to interact with a person in crisis. 
• How to connect a person with help.  
• Expanded content on trauma, substance use and self-care.

The training is divided into three parts:

Part 1 starts AFTER initial registration has been APPROVED by the instructor. Approved registrants will be emailed instructions on how to create an online profile using MHFA Connect and complete a pre-survey/quiz followed by a two-hour self-paced online course. Registrants MUST complete Part 1 no less than 48 hours (two business days) prior to the scheduled Part 2 session.

Part 2 is a 5.5-hour live instructor-led virtual training. Participants are required to be on camera the entire time.

Part 3 participants will return to MHFA Connect to complete the post-test and evaluation, which is required to receive a certificate of participation. 
 

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