Products to Support Applied Research Towards Zero Suicide Healthcare Systems (R43/R44 Clinical Trial Optional)

Research Objectives

This FOA supports the development of health IT products to advance the “Zero Suicide” goal of preventing suicide attempts and deaths among individuals under care within health systems.  A significant proportion of U.S. suicide decedents (more than 40,000 annually) have accessed health care within the year of their death, with estimates ranging from 30% to 80%, mirroring the broader population access to health care. Approximately one-quarter of suicide decedents had treatment for psychiatric issues prior to their death.  The Zero Suicide approach was developed specifically to target health and behavioral healthcare systems and to provide them with a specific set of health care strategies and tools for the reduction of suicide events within facilities, as well as for individuals in the community who are linked to the care system.

Burden of Suicidal Behavior in Health Systems. Since 1995 the Joint Commission has consistently listed suicide among the top 5 sentinel events, i.e., unexpected occurrences involving death or serious physical or psychological injury, in health care settings. Of the 1.3 million individuals in the US who reported making a suicide attempt within the past 12 months, about 6% also reported receiving treatment in an outpatient mental health clinic (estimated 206,000 cases). Rates of individuals reporting attempts within the year have also been estimated for those receiving care in other settings that include: those receiving substance use treatment (5%, estimated 122,000 cases); and those having accessed emergency care in the same year (1%, estimated 728,000 cases). Despite the large number of suicide events among persons receiving healthcare, only 28 states require health care systems to report adverse events that include suicide deaths and attempts, that occur during or following receipt of services. Lack of information about the rate and nature of suicide events within and between care systems hinders efforts to eliminate these adverse events through quality improvement initiatives.

A Learning Healthcare System to Reduce Suicidal Behavior. A learning healthcare system links suicidal behavior outcomes to care processes and service use patterns, considers what care improvements can be tested to reduce suicidal behaviors, and measures the impact of care improvements. Several systems-level improvements have been associated with lower suicide risk in health care organizations like the Henry Ford Health System, the Veterans Health Administration, and mental health services in England and Wales. These system level improvements include (1) providing 24-hour crisis teams; (2) managing patients with co-occurring disorders (e.g., mental and substance use disorders); (3) conducting multidisciplinary reviews of suicide deaths; (4) sharing information with families after a suicide and making future care improvements as a result; (5) removing ligature points from inpatient settings; (6) conducting follow-up with patients within a week of discharge; (7) conducting assertive community outreach; (8) providing regular training to frontline clinicians on the management of suicide risk; (9) responding to patients who do not comply with treatment; (10) sharing information with criminal justice agencies; and (11) reducing access to lethal means, such as firearms. The largest systems-level study found that suicide deaths decreased most in care settings that implemented the greatest number of improvements. The incorporation of more technologies into these service streams could accelerate the implementation and adoption of these approaches into more service settings, and enhance the existing ones.

In the US, a number of subgroups within health care systems have been found to have higher risk. Target subgroups have been defined by service characteristics (e.g., patients who are new to a system; individuals transitioning from one care setting to another; patients who drop out of treatment), as well as by individual patient characteristics (e.g., particular age and gender groups; those with psychotic disorders; substance abuse; chronic pain) or health history (e.g., having made multiple suicide attempts).  The development and evaluation of novel technological approaches is in line with the objectives of the Zero Suicide initiative and these approaches will likely be essential components of strategies to identify and provide treatment to individuals within health and behavioral health systems who are at high risk.

Applications submitted to this FOA should propose a research strategy focused on the development and testing of technologies that are intended to reduce suicide events (attempts; deaths) and frequent precursors (e.g., suicide ideation) among individuals in health care systems.    This FOA encourages SBIR applicants to establish multidisciplinary collaborations with organizations that have infrastructure already in place regarding suicide prevention at the state, federal and local level.  Examples of collaborations include:  1) state collaborations in order to utilize morbidity and mortality surveillance systems (many supported by CDC, http://www.cdc.gov/injury/wisqars/ and http://www.cdc.gov/injury/wisqars/nvdrs.html); 2) collaborations with states that are implementing laws regarding provider training in suicide mitigation and may need technologies to assist with training, monitoring provider skills, and monitoring outcomes; 3) leveraging federal investments that support behavioral health needs (SAMHSA funded services within states: http://www.samhsa.gov/grants-awards-by-state), and primary care (HRSA funded services within states: http://datawarehouse.hrsa.gov/Topics/HrsaInYour.aspx) are also important opportunities, as a number of these investments include suicide prevention as bench mark outcomes; 4) collaborations with healthcare centers engaged in the Zero Suicide effort who can provide the necessary healthcare settings and expertise to test feasibility and implementation of the technology developed under this effort. 

Small business applicants are also encouraged to review the Prioritized Research Agenda for Suicide Prevention regarding the state of the science and potential gaps that technologies could fill.

Research Topics

This FOA supports the development, testing and validation of novel technologies with commercial potential that enable or enhance healthcare organizations' abilities to advance the Zero Suicide agenda.  Examples of the types of capabilities needed are listed below: 

• improve suicide risk detection and screening
• collect data from smartphones, apps and/ or other digital monitoring using pragmatic population based designs.
• enable timely or real-time monitoring of care
• implement efficient (less costly) healthcare delivery
• enhance surveillance of suicide ideation, behaviors and deaths among individuals within health care systems. 
• enable healthcare settings to evaluate effective training approaches for evidence based interventions (e.g. safety planning, psychotherapy) to reduce suicide attempts. 
• rapidly identify and provide effective targeted interventions for: new patients and individuals transitioning into the care system;  those with particular types of disorders (e.g., psychotic disorders; substance abuse; chronic pain);  and those who disengage from care and may require extensive outreach for adequate treatment. 
• rapidly identify barriers to suicide prevention in large care settings (staffing, reimbursement, system and provider liability, training), as interventions are executed and evaluated.
• facilitate the identification of effective service delivery components that work as safety nets to prevent suicidal events.  An example would be the development of tracking systems utilizing electronic medical records and existing databases to both preemptively identify needs for safety nets within a care system with the capability of determining the effectiveness of implementation.
• create linkage of care systems infrastructure to existing surveillance and data sources (e.g.  https://www.facs.org/quality%20programs/trauma/ntdb) supported by CDC, HRSA, Justice, SSA, or private entities.  These products are intended to enable researchers and policy makers to effectively mine existing data sources.

It is expected the technology being proposed is leading edge and that updates/improvements will be anticipated to the extent possible.  Applicants should consider the technology's use in a variety of health care settings relevant to implementing Zero Suicide, including behavioral health and substance abuse outpatient clinics, emergency departments and crisis care programs and centers, hospitals, and integrated primary care programs. 

Applications submitted to this FOA may identify other important, innovative and impactful technologies not listed in the examples above.  Small business applicants considering applying to this FOA are encouraged to contact the Scientific/Research Contact for this FOA for additional guidance prior to submitting an application.    

See Section VIII. Other Information for award authorities and regulations.