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Patient Safety Protocol
Patient safety is a priority at Override. Up to 60% or more of chronic pain patients will have concurring anxiety or depression.1-2 This document outlines our protocols for anxiety and depression screening, assessment, and risk management.
Bottom line: Any provider on Override’s care team (not just behavioral health providers) may learn of a patient’s suicidal thoughts or plans. While not every provider will be responsible for administering assessments and monitoring mental health progress, every provider is responsible for following the protocols detailed below if you are faced with a patient that you fear is at risk for suicide.
Mental Health Screening
All Override patients are screened for anxiety and depression using the GAD-2 (a condensed version of the GAD-7) and PHQ-2 (a condensed version of the PHQ-9) during the intake process and in monthly surveys. The assessments should be reviewed by any team member who is treating the patient and by the medical director monthly.
If a team member notes that the PHQ-2 is 3 points or greater or the GAD-2 is 3 points or greater, they are to check that a follow-up PHQ-9 or GAD-7 (the longer versions), respectively, has been sent to the patient to complete. The team member will notify the physician caring for the patient.
Assessments
GAD-7 interpretation
When screening for anxiety disorders with the GAD-7, a score of 10 or greater represents a reasonable cut-point for identifying probable cases of generalized anxiety disorder. If the score is over 10, further diagnostic assessment by a behavioral health professional is warranted to determine the presence and type of anxiety disorder.3-5
The following cut-offs correlate with the level of anxiety severity:
A meaningful change is 5 or more points.
If there is an increase in score by 6+ points:
Potential interventions to address concerns according to individual questions in the GAD-74:
Source: Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24-31.
PHQ-9 Interpretation
When screening for depressive disorders with the PHQ-9, a score of 10 or greater represents a reasonable cut-off point for identifying probable cases of depression. If the score is over 10, further diagnostic assessment by a behavioral health professional is warranted to determine the presence and type of depressive disorder.
Note: Question 9 of the PHQ-9 is a single screening question on suicide risk. A patient who answers yes to question 9 should receive immediate further assessment for suicide risk by a licensed professional who is competent to assess this risk.
Determining clinically significant change is done by exhibiting a person moving from a depressed range (scores greater than or equal to 10) pre-treatment to a non-depressed range (scores less than or equal to 9) post-treatment. Improvement in scores should be 50% or greater of the patient’s pretreatment score; a 5-point or more change in scores indicates reliable change.
Potential interventions to address concerns according to individual questions in the PHQ-9:
Source: Instruction Manual: Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures. Available at: https://phqscreeners.pfizer.edrupalgardens.com/sites/g/files/g10016261/f/201412/instructions.pdf. Published December 2014
Suicide Risk
Identification of individuals at risk for suicide while under Override’s care and following discharge is an important step in protecting those at risk.
For patients at risk (those who have expressed ideation or have severe depression), the following details should be asked at the beginning of each patient encounter: the patient’s current location (specific address), phone number, others in the home, and emergency contacts. In the case of an emergency, the provider may need to call the emergency contact to assist in evaluating a client’s safety or transporting a client needing a higher level of care.
Determining Need for and Conducting Suicide Risk Screening:
Clinicians must document and notify Override’s medical director if they become concerned by emotional or behavioral disturbances exhibited by a patient at any time. The issue should also be raised at an Override interdisciplinary meeting.
Managing a patient with passive suicidal ideation:
If you are interacting with a patient who has passive suicidal ideation (i.e., has thoughts of hopelessness and suicide but does not have a plan, means, or intent) during their visit with you:
Managing a patient with active suicidal ideation:
If you are interacting with a patient who is actively suicidal (i.e., plan, means, intent) during their visit with you:
Screening for Suicidal Ideation: Another possible tool (outside of verbal interaction with patients) to evaluate patients who exhibit emotional or behavioral disturbances is a validated screening tool for suicidal ideation (such as the Columbia-Suicide Severity Scale (C-SSRS)). The C-SSRS is available for use in Healthie. If administered, interventions for the safety of the patient will be implemented based on the risk level determined by the provider and the patient’s risk assessment.
If the scale is used, then the provider should conduct a reassessment at a minimum of a change in patient status (as determined by the provider) or at the next follow-up appointment. Reassessment will include the risk level of the patient with suicidal ideation.
Bottom line: If you are worried that the patient will harm themselves imminently, then call 911, the patient’s emergency contact, and Override’s medical director.
References
Last Updated: February 3, 2022
