Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care

Abstract

Introduction:

Veteran patients have access to a broad range of healthcare services in the Veterans Heath Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The MISSION Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at higher risk of poor health outcomes. This is a particular concern with regards to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings.

Materials and Methods:

A retrospective analysis of root-cause analysis reports (RCAs) and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety (NCPS) between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root-causes reported in RCAs were also coded and the factors that contributed to the events described in the patient safety reports. Two reviewers independently coded ten cases and we then calculated a kappa. Because the Kappa was greater than 80% (i.e., 89.2%), one reviewer coded the remaining cases.

Results:

Among 139 potentially eligible reports, 88 reports were identified that met study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were due to healthcare related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment. For example, access to methods of strangulation in community care treatment settings in a emergency room or rehabilitation unit.

Conclusion:

It is important to strengthen systems of care across VA and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA and VA-contracted community care organizations.

Introduction

The Veterans’ Health Administration (VHA) is the largest, integrated healthcare system in the United States, with more than nine million Veterans covered.¹ While the VHA offers a broad range of healthcare services,^{2, 3} there are concerns that Veterans who access VHA care may not receive well-timed care.⁴ In response, congress passed legislation to increase Veteran access to care.⁴ This includes the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in 2018.⁴ The goal of the MISSION Act is to leverage care in the community to ensure that all eligible Veterans receive timely, high quality care, regardless of their place of residence.^{1, 4} If an eligible Veteran is unable to access necessary care within a VHA facility (or its subsidiary),¹ the Department of Veterans Affairs (VA) pays a community provider enrolled in the Community Care Network (CCN) to deliver this service.⁵ The CCN includes provider networks that are overseen by Third Party Administrators (TPAs) or managed by individual Veterans Care Agreements between the VA and the community care provider.⁵ To be eligible to join the CCN, providers must meet eligibility criteria and complete required training.⁵ As of 2018, 1.8 million Veterans had accessed VA-contracted community care and it is anticipated that at a minimum, this number of Veterans will continue to access these services.⁶

While the intent of VA-contracted community care is to increase Veterans’ access to timely and high-quality care, there are concerns that these transitions of care may place Veterans at risk for poor outcomes.⁷ This may be especially true in the case of mental health treatment⁸, increasing the risk of worse outcomes, including suicide.^{9, 10} Unlike the community hospital setting, the VHA has a robust, standardized suicide prevention program across the enterprise.^{2, 3} Each VHA facility is staffed with at least one suicide prevention coordinator who oversees local suicide prevention efforts in all setings.² In comparison, Veterans who receive care in the community may have limited or no access to these critical resources.⁹ Moreover, it is possible that Veterans who are simultaneously accessing care at a VHA and in the community may be at risk of experiencing disruptions in care related to transitions in care.⁸ These circumstances could result in fragmented care and low continuity of care is associated with risk of suicide.^{11, 12}.

To date, no study has examined suicide-related safety events in Veterans who access care at both the VHA and VA-contracted community care. An analysis of these event reports will provide valuable insights into the role that healthcare processes can play in contributing to (or mitigating) suicide-related events during this transition scenario. To address this critical knowledge gap, an analysis of suicide-related safety events by Veterans that received treatment in a VA-contracted community care setting was conducted. The aim of our study is to provide the VHA and its community partners with key information about the scope of the current problem and to recommend steps that the VHA (and its partners) can take to mitigate risk of suicide in this population.

Methods

Study design and data sources

A retrospective analysis of suicide-related safety events was conducted that involved VA-contracted community care and were reported to the VHA National Center for Patient Safety (NCPS) between January 1, 2018, and June 30, 2022. The study was reviewed by the VA Institutional Review Board of Northern New England (VINNE) and deemed to be exempt.

Two robust databases that are managed by NCPS, including the Joint Patient Safety Reporting System (JPSR) and the Root-Cause Analysis (RCA) database were used as data sources.¹³ The JPSR is a standardized, voluntary reporting system that captures data on medical errors and near misses.¹³ VHA healthcare teams are encouraged to report any adverse events or near-misses that occur in a VHA¹³ or VA-contracted community care setting.¹⁴ Findings from the patient safety reports are then used by local VHA patient safety managers (PSM) to inform ongoing safety and quality improvement efforts.¹⁴ The RCA database contains the reports of any RCAs that were performed at a VHA facility.¹³ RCAs are led by local, VHA PSMs and include a multidisciplinary team that makes use of standardized materials to determine the root causes and systems issues that lead to an adverse event.¹⁵ RCAs must be performed to investigate sentinel events, serious safety events, and any event that “poses a substantial, direct, and high probability that a serious safety event would have occurred but did not occur due to intervention or chance (page 5).”¹⁵ A facility may perform a single or aggregate RCA of other adverse events to support local safety and quality improvement efforts.

While a TPA’s Quality and Patient Safety Representative may participate in the review of safety events related to VA-contracted community care, any discussions regarding patient safety and quality between VHA and community providers are protected by law.¹⁴ There is no contractual requirement that TPAs disclose information on individual cases to VHA PSMs¹⁴ or that community providers participate in a RCA. Nevertheless, the VHA encourages TPAs to provide the results of any internal patient safety analysis and values the cooperation of community providers in completing the PSM led, RCA process.

Inclusion criteria and identification of included reports

Because little is known about suicide-related safety events that involve VA-contracted community care, a broad set of inclusion criteria were developed. Reports related to suicide, non-fatal suicide attempts or suicide-related close calls (e.g., suicidal ideation with plan) were included if the circumstances surrounding the event included any contact with VA-contracted community care. According to the VHA Patient Safety Events in Community Care Guidebook, VA-contracted community care refers to community treatment delivered via TPAs, regional contracting vehicles, memorandums of understandings, VA medical center-level contracts or agreements, or other specialty contracts.¹⁴ Some examples of VA-contracted community care include psychiatric hospitalization or skilled nursing.¹⁴ A stipulation was made that the actual (or anticipated) care in the community occurred within approximately three months of the event. This decision was made because of the concerns that healthcare contacts beyond this time frame would be increasingly more difficult to attribute to the event itself. In the case of psychiatric hospitalization, there is ample evidence that patients are at high risk of suicide within the first three months of discharge from the healthcare setting.¹⁶

To identify eligible reports, all reports of suicide-related events reported in the JPSR (or the RCA database) between January 1, 2018, and June 30, 2022, were searched. These events were filtered based on the reporting facility selected “yes” in response to the question. “Does this event involve community care?” To mitigate the possibility that the initial search overlooked otherwise eligible reports, text fields were searched within each potentially qualifying report using natural language processing terms related to community care such as “care in the community,” “Mission Act,” “Tri-West,” or “Optum.” (Tri-West and Optum are TPAs that have contracted with the VA to administer community care). Eligible reports were screened by two authors independently to identify those reports that met inclusion criteria. Any discrepancies between screeners were resolved through consensus.

Data abstraction and analysis

Based on prior work examining healthcare processes related to suicidal behavior in VHA settings¹⁷ and recommendations in the RCA guidebook,¹⁵ a code book was developed. The codebook included basic information on the report type as well as facility and patient characteristics. We coded the event type (death or attempt) and the method of self-harm. We treated suicides (or non-fatal suicide attempts) as confirmed events if the report referred to conclusive evidence to support the decision. We treated a suicide (or non-fatal suicide attempt) as probable events if the report indicated that inconclusive evidence was present to support the decision. In addition, we coded the proximity of the event to VA-contracted community care treatment.

With regards to the RCA, root-causes were coded as documented by the clinical team. All available data that was described in the report were reviewed. This included going over the description of the event, the clinical team’s final understanding of the event, and any contributing factors to the event. For completeness, any additional root-causes that the local teams may have overlooked were coded. Although RCA reports include the clinical team’s overall impression about the root cause(s) that led to the event individual teams are sometimes restricted to the examination of a single event of a rare outcome. As such, the teams may lack the benefit of observing patterns or trends of problems that emerge as themes across reported events. This approach is consistent with prior work in this area.¹⁷ In review of the patient safety reports, the contributing factors that providers had identified as playing a role in the event were coded. We coded whether the providers reported that the VHA (or community care) had successfully taken steps to mitigate (or avoid) harm related to the event.

Two reviewers (NR, CS) independently coded ten cases using the coding book. A Kappa greater than 80% was considered excellent agreement. A Kappa of 89.2% resulted from the agreement between reviewers. Therefore, one reviewer (NR) completed coding of the remaining cases.

Results

The initial search identified 139 reports. After screening each report by hand and applying inclusion criteria, 55 reports were removed that did not meet eligibility criteria resulting in a total of 88 included reports. Of these 88 reports, 62.5% were patient safety reports (N=55) and 37.5% were RCA (N=33) (see Table 1). Sixty-eight percent of reports were conducted at facilities located in urban settings.

Table 1.

Features of reports of suicide-related safety events linked to VA-contracted community care

	Root-cause Analysis % (n)	Patient Safety Reports % (n)
Total reports	33	55
Facility and Patient Characteristic ^
Location of facility
< 50% of population live in rural area§	70.0 (23)	67.3 (37)
≥ 50% of population live in rural area§	30.0 (10)	32.7 (18)
Gender
Male	90.9 (30)	84.0 (46)
Female	3.0 (1)	7.0 (4)
Not reported	6.1 (2)	9.0 (5)
Event Characteristics
Event Type
Confirmed death by suicide	63.6 (21)	13.0 (7)
Possible death by suicide	12.1 (4)	4.0 (2)
Confirmed non-fatal suicide attempt	21.2 (7)	65.0 (36)
Possible non-fatal suicide attempt	3.0 (1)	9.0 (5)
Other suicidal behavior	0.0 (0)	9.0 (5)
Method of injury
Firearm	36.0 (12)	15.0 (8)
Overdose (e.g., prescription, illicit drugs)	21.0 (7)	35.0 (19)
Hanging/Strangulation	18.0 (6)	13.0 (7)
Cutting	3.0 (1)	16.0 (9)
Other method	3.0 (1)	5.0 (3)
No method reported	18.2 (6)	16.0 (9)
Proximity of event to community care treatment
Inpatient medical-surgical unit
Event occurred during admission	3.0 (1)	1.8 (1)
Event occurred ≤ 3 months of discharge	6.1 (2)	0.0 (0)
Inpatient psychiatric unit
Event occurred during admission	3.0 (1)	0.0 (0)
Event occurred ≤ 3 months of discharge	27.3 (9)	10.9 (6)
Skilled nursing, rehabilitation, assisted living, or nursing home
Event occurred during admission	3.0 (1)	16.4 (9)
Event occurred ≤ 3 months of discharge	3.0 (1)	0.0 (0)
Emergency room
Event occurred during admission	0.0 (0)	1.8 (1)
Event occurred ≤ 3 months of discharge	3.0 (1)	1.8 (1)
Outpatient setting
Event occurring residential admission	6.1 (2)	18.2 (10)
Event occurred while receiving outpatient care	39.4 (13)	10.9 (6)
Other setting
Event resulted in community hospital admissionǂ	6.1 (2)	38.2 (21)

^{^}Because the majority of reports were missing information on the age of the patient, we did not report this patient characteristic in the table.

^§Criteria to define rurality are derived from definitions that the Department of Veterans Affairs Office of Rural Health uses to categorize facilities as rural versus not-rural.

^ǂPatients were typically admitted to the community hospital inpatient psychiatric unit or medical ward for treatment of a recent suicide attempt

There were several differences between RCA and patient safety reports. More than 50% of RCAs were chartered to examine a confirmed suicide and the most common method used was firearm (36%). Conversely, most patient safety reports referred to a confirmed non-fatal suicide attempt (65%) and the most common method was overdose (35%). In the case of RCA, the event occurred after a community psychiatric hospitalization (27%, N=9) or while a patient was receiving outpatient care in the community (39%, N=13). On the other hand, a large proportion of patient safety reports (38%, N=21) described a safety event that occurred while a patient was admitted to a community care hospital or residential program.

Many safety reports (N=21, 38%) reported on suicide attempts that occurred in the community outpatient setting (e.g., individual’s home) and were subsequently treated in a community hospital. Because surveillance is essential to VHA suicide prevention, this represents a critical opportunity for community providers to engage in these efforts.

Root-cause analysis reports

As shown in Table 2, 129 root causes of suicide-related safety events among patients who received VA-contracted care in the community were identified. Many of these root causes (N=111) were attributed to healthcare related processes. The reports suggested that deficiencies in mental health treatment and communication challenges were key factors in events. For example, VHA providers encountered challenges in coordinating care with community providers. In some cases, the community providers did not notify the VHA of a patient’s admission or did not respond to requests for clinical information. VHA providers also did not convey pertinent information to community providers. These lapses in communication resulted in suboptimal, nonintegrated care. Some reports described that because of poor communication, the patient was discharged from the community hospital with no follow-up care, or the patient received inadequate treatment of other symptoms such as pain. Existing processes of care may not be designed to facilitate a smooth transition between care settings. For example, a RCA report highlighted that while the VHA offers a mental health treatment that is designed to address the needs of patients with severe mental and physical illnesses, this treatment was not available in the rural, community setting. Although the VHA has a robust mechanism for scheduling post-discharge care among patients discharged from VHA facilities, another RCA report suggested that a similar process did not exist for patients who are discharged from community hospitals. Some reports cited delays in VHA completion or tracking of community referrals.

Table 2.

Root-causes of suicide-related safety events among Veterans who received VA-contracted care in the community

	Root Causes	Descriptive Examples
Variable	N	VA-related factors	Community Care – related factors
Total root causes	129	-	-
Healthcare process related causes (N = 111)
Deficiencies in mental health treatment	34	• No safety plan completed. • No follow-up on community care referral. • No follow-up care arranged after discharge. • Delays in scheduling MH treatment. • Inadequate treatment of comorbid symptoms.	• No safety precautions during inpatient stay. • No follow-up care arranged after discharge. • Abrupt cessation of pain medications. • No medication provided at discharge. • Inadequate treatment of comorbid symptoms
Communication challenges	33	• Failure to relay clinical info to community care providers. • Failure to relay clinical info to other VA staff about a patient hospitalized in community.	• Failure to notify VA staff of care received in the community (e.g., hospitalization). • No response to VA request for clinical info. • Unavailable to participate in PS/QI activities.
Inadequately designed processes of care	21	• No streamlined process to schedule follow-up for patients treated at a community site. • Facilities differ in their approach to gathering clinical information from community sites.	• Indicated MH treatment not available in community in rural location. • Fewer treatment resources available during weekend discharges.
Problems with the suicide risk assessment	11	• Suicide risk assessment not completed. • Contraband search not completed.	• A single report cited problems with suicide risk assessment during community care (i.e., misclassification of a suicide attempt).
Unsafe environment	7	• Two reports mentioned concerns about the safety of VA clinical environment (e.g., access to contraband on VA unit after brief transfer to community hospital for care).	• Access to method to hang self on inpatient psychiatry unit. • Access to method to hang self on medical-surgical floor.
Issues in VA community care office	5	• Delays in completing referral requests. • Community care coordinators not aware of processes for reporting suicidal behavior.	• Lack of a process for non-VA clinic to bill VA properly for pain management. As a result, community care ceases care.
Patient related causes (N = 18)
Low treatment engagement by patient	18	• Patient declines mental health treatment. • Patient no-show appointment.	• Patient requests that community care provider cease all communication with VA providers.

MH = Mental Health; N = Number; PS/QI = Patient Safety/Quality Improvement; VA = Department of Veterans Affairs

A small number of root causes (N=18) were attributed to patient factors. There were concerns that some patients had low treatment engagement which may hinder coordination of care between VA and community providers. For example, one RCA report mentioned that the patient would not consent to contact between the community provider and the VHA. As a result, the community provider ceased communication and VHA providers were no longer aware of the patient’s clinical status.

It is important to point out that a few RCA reports highlighted concerns that community provider(s) were not available to participate in patient safety activities including sharing information around an adverse event that occurred in the community setting. As such, the RCA report noted that their interpretation of the event was limited and likely, not comprehensive.

Patient safety reports

The patient safety reports identified 64 problems that may have played a role in suicide-related safety events among patients who received VA-contracted care in the community (see Table 3). The most common cited problem was an unsafe environment in the community setting. For example, a patient who was hospitalized in a skilled nursing facility had access to a bed control cord as a method of strangulation. In another case, a patient who was hospitalized on a medical-surgical unit overdosed on prescription medications. The provider completing the safety report mentioned that they had insufficient information from the community care site to determine whether the patient had been assessed for suicidal ideation during the stay, or whether any safety precautions were in place during the stay.

Table 3.

Key findings in patient safety reports of suicide-related safety events among Veterans who received VA-contracted care in the community

		Descriptive Examples
Variable	N	VA-related factors	Community Care – related factors
Identified Problems (N = 64)
Unsafe environment	21	• A single report mentioned concerns about the safety of VA clinical environment (i.e., access to medications in urgent care clinic).	• Access to cord from call light in ED bathroom. • Access to O2 tubing on nursing home floor.
Deficiencies in mental health treatment	17	•No follow-up care arranged after discharge from community care hospital. • No safety plan completed. • No safety precautions during ED stay.	• No follow-up care after patient reported suicidal statements during outpatient visit. • No follow-up care arranged after discharge. • No safety precautions during inpatient stay.
Communication challenges	13	• Failure to relay clinical info to other VA staff about a patient treated in community. • Failure to relay clinical info to community care providers during patient transfer.	• Failure to notify VA that a patient was hospitalized for treatment of a suicide attempt. • VA staff unable to reach community care providers to coordinate clinical care.
Problems with the suicide risk assessment	7	• Suicide risk assessment not completed.	• Suicide risk assessment not completed
Other problems	6	• Patient declines MH treatment and admission to VA hospital for treatment. • Billing incident results in community care provider cancelling MH treatment.	• Limited information on event because no RCA available from community care site. • Prior to event, there were issues with the ED suicide risk protocol at the site.

ED = Emergency Department; MH = Mental Health; N = Number; RCA = Root-cause Analysis; VA = Department of Veterans Affairs

As with the RCAs, the patient safety reports highlighted that deficiencies in mental health treatment and communication challenges were of concern. As an example, VHA providers were not made aware of a patient who was hospitalized after a suicide attempt and no follow-up care was arranged following a community care discharge. In some cases, there was miscommunication between providers. For example, VHA providers did not inform community providers about suicidal ideation prior to transfer. Aligned with concerns raised in the RCAs, a few safety reports suggested that the community site was not engaged in actions designed to improve quality and safety. For example, although an adverse event occurred within seven days of discharge from the community care setting, it was the understanding of the reporting provider that the community care site had opted against conducting an RCA.

While the patient safety reports pointed out several gaps in care that contributed to suicide-related safety events in the community, the reports highlighted that there are instances where the VHA and community providers can work together to mitigate suicide risk. There were 31 patient safety reports of the VHA being notified in a timely manner about a suicide attempt in the community. There were six patient safety reports that described that VHA providers were able to coordinate follow-up care for a patient discharged from a community care setting.

Discussion

Eight-eight reports of suicide-related safety events that involved VA-contracted community care were identified. The majority of events were reported through the patient safety reporting system, while the remainder were reported as part of an RCA. Patient safety reports primarily reported confirmed non-fatal suicide attempts that occurred during an admission in a community care setting or resulted in a community hospitalization. RCA reports primarily reported on confirmed suicides that occurred after a community hospitalization or while a patient was receiving outpatient treatment in the community. Across reporting methods, there were consistent concerns that deficiencies in mental health treatment and communication challenges were factors in suicide-related safety events associated with VA-contracted community care. Patient safety reports pointed to concerns that patients had access to lethal means during their admission in community settings. RCA reports suggested that low treatment engagement on part of the patient posed challenges in the delivery of care across treatment settings. Finally, both RCA and JPSR reports relayed specific concerns that community providers were not engaged in VHA patient-safety activities including sharing information to inform adverse event analysis.

The finding that poor communication may contribute to suicide-related safety events among patients who receive VA-contracted community care aligns with prior concerns raised in the literature.^{8, 18–20} Communication is frequently cited as a factor contributing to safety events²¹ including in psychiatric settings.²² In an opinion piece published in JAMA Psychiatry in 2020, Aggarwal suggested that there are several potential negative ramifications of the VA MISSION Act⁸ that may further exacerbate these known concerns. This includes key vulnerabilities in the delivery of information across systems. The VA has implemented a HealthShare Referral Manager to enable VHA and non-VHA providers to coordinate care. As part of this system, non-VHA providers can see VHA clinical documentation (e.g., consults).⁸ Providers can communicate with each other via encrypted email. Nonetheless, aligned with Aggarwal’s concerns, it was found in our study that providers still encountered problems with miscommunication using these tools. For example, a non-VHA provider was unaware that a VHA provider was unable to view a discontinued consult. Aggarwal draws attention to the fact that VHA providers are generally unable to view community electronic health records (EHR).⁸ As such, providers are highly reliant on each other (and the patient) to glean information about treatment delivered in VHA and community settings.

The Joint Commission has put forth evidence-based recommendations to improve communication in healthcare settings.²¹ Leadership should strengthen systems to enhance communication and embrace patient safety principles.²¹ The processes for communicating critical information should be standardized.²¹ The environment should be conducive to relaying information between parties (e.g., free of interruptions).²¹ Providers should receive standardized training in communication (e.g., Identification Situation Background Assessment Recommendation (ISBAR)).²¹ Research has found that the VHA clinical team training program, in particular, is highly effective in improving communication and reducing patient harm including mortality.²³ The clinical team should make use of EHR to facilitate communication. There should be ongoing assessment of the impact of interventions on processes and systems in place to maintain improvements.²¹ Because the VHA is currently rolling out a new EHR, that is compatible with non-VHA EHR, this may facilitate better communication across VHA and non-VHA healthcare settings.⁸

Several RCA and patient safety reports mentioned concerns about deficiencies in mental health treatment. The deficiencies in mental health treatment frequently appeared to be the direct result of lapses in communication within and across settings. For example, VHA providers were not notified that a patient was discharged from a community hospital and as a result, the patient did not receive follow-up care. Other reports raised concerns specific to suicide prevention such as a patient being discharged from a community hospital without a safety plan. Researchers have highlighted that while the VHA has developed an extensive program to address the risk of suicide in Veterans, similar programs do not exist in the community.^{9, 10} Our findings suggest that VA-contracted community care sites may benefit from these programs. The VHA does encourage community providers to attend free webinars that cover a range of topics including suicide prevention.²⁴ Finally, VHA providers may require training in community care related issues.

Another key finding included environmental hazards being frequently cited as a concern in VA-contracted community care settings. Unlike community settings, the VHA has implemented system-wide strategies to address environmental factors that may contribute to risk of suicide in supervised, clinical settings. Notably, VHA psychiatric units are required to use the Mental Health Environment of Care Checklist (MHEOCC) to mitigate potential harm to patients (e.g., removal of anchor points for potential hanging). The VHA has found that the implementation of the MHEOCC resulted in a significant reduction in the rate of suicide across VHA psychiatric units.²⁵ The rate of suicide on VHA psychiatric units is lower than those of civilian, inpatient psychiatric units.^{26, 27} While suicidal behavior remains a concern in other VHA clinical settings (e.g., medical-surgical unit, residential),²⁶ prior research has reported that the rate of suicide in VHA community living centers (2.11 per 100,000 admissions)²⁶ is lower than that of nursing homes (14.16 per 100,000 older adult, nursing home residents). ²⁸ Together these findings suggest that there may be a role for the VHA to share lessons learned around the management of environmental hazards with VA-contracted community care settings.

Several instances of successful handoffs were noted where community providers notified VHA providers of a suicide attempt to facilitate risk mitigation and improve care, conversely, we reviewed several reports that raised concerns that community providers were unavailable to participate in patient safety activities. This limited the RCA team’s ability to evaluate the safety event and to improve processes of care to mitigate risk. Aligned with this observation, few reports of close calls relative to reports of serious adverse events were identified. Close calls occur up to 300 times more often than adverse events.²⁹ As such, the reporting and analysis of close calls is critical to establish a safe system of care.^{29, 30} The VHA has a robust patient safety program including a national, standardized reporting system.¹³ VA-contracted community providers, however, do not have access to the VHA’s patient safety reporting system (i.e., JPSR). If these providers choose to self-report on adverse events or close calls involving Veteran patients, they must rely on VHA providers to document this information in JPSR.

Low treatment engagement was named as a factor in several suicide-related safety events within this study pointing to the need to study interventions that can increase treatment engagement and reduce the risk of suicide in patients who access VA-contracted community care. In a quasi-experimental study of an enhanced safety planning intervention in VHA emergency rooms, Stanley et al., found that the intervention was associated with significantly lower odds of suicidal behavior.³¹ Riblet et al. found that a suicide prevention strategy called the VA Brief Intervention and Contact Program may reduce suicidal ideation and increase treatment engagement in Veterans who are discharged from a VHA psychiatric unit³² or treated in a primary care mental health walk-in clinic.³³ Neither of these interventions have been tested in patients who access care in VA-contracted community care settings.

Our work is rather novel because we are the first study to examine suicide-related safety events involving VA-contracted community care. There are limitations to the findings, however. Because the data collection relies on voluntary reporting systems, it is likely that the results are not representative of all suicide-related safety events that occur in this population. We are unable to determine the frequency of suicide-related events in community care or compare these rates against VHA care. Published suicide data are only available through 2020³⁴ and there are challenges in identifying suicide-related events.^{35, 36} Future research should develop robust approaches to quantify and characterize suicide-related events involving community care and design effective solutions.

Our analysis is limited to data reported through VHA providers. We have no knowledge about the response of community providers to the event (e.g., institutional RCA) and do not know whether there were other pertinent facts about the event that were not accessible to the reporting, VHA provider. Thus, the precise role of the VHA and community care remains unclear. Because events are tied to healthcare activities, they will not represent all suicide-related events. Reporting bias is of concern.³⁷ We cannot generate reliable estimates of the prevalence of root causes. Our study does not address confounding. Finally, the analysis does not include a patient perspective. In a qualitative study of 51 Veterans, Miller et al. 2021 found that patients cited opportunities (e.g., patient-centric care) and challenges (e.g., patient acts as care-coordinator) in accessing VA-contracted community care.³⁸

Conclusions:

Overall, this study suggests that there are opportunities to strengthen systems of care to reduce the risk of suicide in patients who access VA-contracted community care. Developing national standards of care for community care providers to demonstrate a safe environment of care for suicidal patients and the use of evidence-based mental health assessment and treatment will strengthening systems of care. Requiring that community providers demonstrate proficiency in suicide prevention may standardize care. It is necessary to develop standard methods of communication between VHA and community providers to include ongoing electronic communication and verbal follow up especially for high-risk situations such as psychiatric discharge. Patients would benefit from robust quality and safety programs that investigate safety events and share results across organizations.

Data availability statement:

The data underlying this article cannot be shared publicly. Root Cause Analyses (RCAs) and patient safety events in SPOT and JPSR events are designated as Quality Assurance documents and as such, contain information that is designated as confidential and privileged under 38 U.S.C. 5705 (herein referred to as 5705) and 5 U.S.C. 522a (Privacy Act).