PROJECT SUMMARY Despite development of evidenced-based treatments and assessment tools, the number of suicide deaths in the US has risen dramatically in the past decade. The suicide rate of outpatients in behavioral health care is 100x higher than the general population, and >25% who die by suicide and >50% of those who attempt receive care in outpatient behavioral health settings in the prior year. Unfortunately, evidenced-based practices have not found their way into routine outpatient care. As such, outpatient clinics are a critical location for suicide prevention efforts, and improving suicide prevention practices holds promise for reducing suicide. The ZS model is a multi-component (including assessment, intervention, and continuity of care), system-wide approach based on the assumption that suicide within the health care system is preventable. Given that the ZS approach is being promoted nationally, it is important to ascertain what factors affect its effectiveness and what intensity of implementation achieves maximal uptake. In this project, we propose to conduct a large scale implementation and evaluation of the ZS model in outpatient behavioral health. We will implement ZS strategies in 145 clinics in New York State (NYS) serving >80,000 behavioral health clients. This project combines efforts with the NYS Office of Mental Health’s Continuous Quality Improvement unit, and benefits from the State's well-developed, existing administrative database infrastructure, including mandated reporting of suicide attempts and deaths for individuals in care and client-, clinic-, and agency-level data on treatment attendance, hospitalizations, and Emergency Department visits. Using a hybrid effectiveness-implementation type 1 design, we will test the effectiveness of ZS in 145 outpatient state licensed (but not state operated) clinics. We will randomly-assign agencies to one of two conditions: “Basic Implementation” (BI) or “Enhanced Implementation” (EI; enhanced training/consultation, use of site champions, participatory learning collaboratives). In Aim 1, we will compare the effectiveness of EI and BI conditions in reducing suicidal behaviors (attempts and deaths), psychiatric hospitalizations, and ED visits. We will conduct cohort and historical comparison analyses to determine the effectiveness of ZS conditions vs “treatment-as-usual." In Aim 2, we will use mixed qualitative-quantitative approaches to compare the EI and BI conditions on implementation and sustainability of the ZS model. We will use the Precede-Proceed framework to evaluate agency- and provider-level predisposing, enabling, and reinforcing factors affecting implementation success, as well as rates and quality of ZS components (process/impact evaluation) during implementation, maintenance, and follow-up periods. This study will be the largest implementation and evaluation of the ZS approach ever conducted, and will provide crucial insight regarding broader dissemination. Results will inform how to best adopt empirically-supported, suicide-safe care, thereby reducing tragic and preventable loss of life.

PROJECT NARRATIVE Over the past decade, there has been a dramatic increase in the US suicide rate, with a significant proportion of those who die by suicide or attempt suicide in outpatient behavioral health care either at the time of the event or in the prior year. We propose to conduct the largest outpatient Zero Suicide implementation ever conducted, by comparing two levels of implementation (basic vs enhanced implementation) of the Zero Suicide model using a cluster randomized hybrid effectiveness implementation design in >100 participating outpatient clinics throughout New York State. The proposed study will serve as a guide for effective outpatient implementation of the Zero Suicide model in behavioral health outpatient settings throughout the country.