Selecting the Right Level of Care for Patients at Risk of Suicide
Behavioral Health Insights
By Micah Hoffman, MD, DABPN, FAPA, QME, CIME, CHCQM
AllMed Behavioral Health Medical Director
About 49,500 people died by suicide in the United States last year, more than in any previous year on record.1 While growing awareness and prevention efforts such as the new national 988 crisis line offer reasons for hope, there is much to do to reverse the trend. As discussed in our previous article, expanding the availability of meaningful, timely risk assessments is essential to reduce suicide deaths. Equally important is ensuring that at-risk patients are referred to the appropriate level of care to meet their specific needs. This article explores the complexities that factor into care-level decisions.
Assessing the Imminence of Risk
Suicidality exists on a spectrum from chronic ruminations to active attempts. Whether a patient is in an acute state or experiencing chronic thoughts, risk assessment is always a provider’s top priority. Evidence-based risk factors include access to lethal means, a prior history of suicide attempts, and co-occurring mental health or substance use disorders. Key protective factors include social support from family and friends and engagement in some level of outpatient treatment. Skilled providers employ expert clinical judgment to weigh the relevance of these factors in determining the imminence of risk and the appropriate level of care.
For a patient in the emergency room (ER), the most crucial step in treatment planning is crisis-focused psychotherapy by a psychiatrist or trained social worker. The provider aims to establish a rapport with the patient and explore symptoms and psychosocial stressors that have culminated in suicidality. As part of the process, the provider collects collateral contact information from the patient’s family, friends, and/or providers. If clinically appropriate, safety planning may be considered. Typical safety planning involves principles of cognitive behavioral therapy, including identifying warning signs, resources, and providers the patient can draw on after leaving the ER (Note that if a patient is initially intoxicated, it’s crucial to reevaluate in a setting of sobriety.)
As highlighted above, gathering collateral information is essential when deciding whether to admit an individual for inpatient care or release them. This corroboration mitigates the possibility of the patient engaging in positive impression management or withholding information to avoid being admitted. For this reason, taking the time for this step is the standard of care in emergency rooms—and a crucial element in identifying the appropriate level of care.
Mental Health Levels of Care
There are several levels of care. The availability of resources at specific levels can vary significantly due to factors discussed in the next section. Descriptions of the levels, from highest to lowest, follow:
Inpatient hospitalization is the highest level of care, typically reserved for patients who are acutely suicidal and in immediate danger. Inpatient hospitalization may be voluntary or involuntary (depending on state laws). Typically lasting no more than a week, inpatient hospitalization may benefit patients who need acute medication management to stabilize them before moving to a lower level of care. It’s important to understand that inpatient care is short-term, acute treatment only and not a cure-all. If the causes of a patient’s suicidality are chronic, such as homelessness or poor psychosocial support, inpatient treatment will not help them.
Residential partial hospitalization is the next-highest level of care, geared toward patients who need more support than outpatient therapy but don’t need full-time supervision. In this type of program, patients live onsite and receive therapy, typically half-day or full-day. Resident advisors provide 24-hour monitoring and support.
Partial hospitalization programs (PHP) and Intensive outpatient programs (IOP) generally include daily (PHP) or several times-a-week (IOP) therapy and medication management but no residential component.
Outpatient therapy is the most common level of care for psychiatric patients. It involves regular therapy sessions with a psychiatrist or therapist. Outpatient therapy can be helpful for patients who are managing their symptoms well but still need support, guidance, and/or medication management.
Ideally, an individual who has engaged in suicidal behaviors or attempts would go from an inpatient facility to a 2- or 3-week residential or intensive outpatient program with support during the transition to reduce suicide risk during this vulnerable time. The goal is to give patients a solid foundation and start them on a positive trajectory so that they can engage in maintenance from then on.
Care Transition Gaps
While seamless, supported transitions are the ideal, the current reality is that barriers to care often impede the progression from one level of care to another. Most significantly, the limited number of beds and mental health resources allows for gaps in treatment to develop. These gaps can be deadly.
A meta-analysis of 48 studies found greatly elevated suicide risk in the year following discharge from psychiatric hospitalization.2 For the first week after discharge, the suicide rate for patients is 300 times higher than for the general population.3 These data highlight the importance of especially close clinical support and patient monitoring throughout periods of early post-discharge, yet too often, patients fall through the cracks when moving from one care level to another.
Many providers, hospitals, and health care plans are focused on narrowing transition gaps between inpatient and outpatient care with strategies to improve collaboration, communication, and patient support. The Substance Abuse and Mental Health Services Administration (SAMHSA) has published Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care to promote effective clinical practices. These best practices emphasize that collaborative planning and shared protocols among care continuum partners are key to the success of these efforts. By working together, healthcare system leaders and clinicians can ensure that people at risk of suicide receive high-quality, evidence-based, continuous care that can ultimately save lives.
Working Together to Provide Comprehensive Support
At AllMed, our board-certified psychiatrists understand the nuances of referring at-risk patients to the right level of care and supporting them through care transitions. Ready when needed, our experts bring extensive training and real-world clinical experience to every review. Rely on AllMed for practical, evidence-based guidance to inform treatment planning for your members with mental health care needs.
- Centers for Disease Control and Prevention. Provisional Suicide Deaths in the United States, 2022. August 10, 2023. https://www.cdc.gov/media/releases/2023/US-Suicide-Deaths-2022.html. Accessed August 11, 2023.
- Forte, Alberto, et al. “Suicidal Risk Following Hospital Discharge: A Review.” Harvard Review of Psychiatry 27,4 (2019): 209-216. doi:10.1097/HRP.0000000000000222 https://pubmed.ncbi.nlm.nih.gov/31274577/. Accessed August 11, 2023.
- Chung, D. T., Hadzi-Pavlovic, D., Wang, M., Swaraj, S., Olfson, M., & Large, M. (2019). Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalisation. BMJ Open, 9(3),e023883. Retrieved from http://dx.doi.org/10.1136/bmjopen-2018-023883.